Beginning and Ending Procedures
Essential Behaviors to All Skills
Skill Task Listing
The following is a listing of skill tasks that you may be asked to demonstrate. Following each task is a list of the steps that should be performed to demonstrate the task. You must be ready to correctly demonstrate each step. The bolded statements are very, very important.
CRITICAL CRITERIA
***Critical criteria include behaviors that are part of EVERY skill tested.
They include:
1. Infection control and body substance precautions (Following all rules of medical asepsis)
2. Safety (Protecting resident and self from physical harm)
3. Residents’ rights (Taking action to prevent or minimize emotional stress to resident)
4. Communication (Explaining procedure to resident prior to initiating it)
5. Recognizing and reporting changes (Observing and reporting abnormalities)
BEGINNING PROCEDURE ACTIONS
1. Wash hands thoroughly prior to entering room or when in room
· Hand washing: Demonstrating hand washing is necessary and is evaluated as part of the critical criteria.
2. Assemble needed equipment
3. Go to resident’s room, knock, and pause before entering
4. Introduce self by name and title
5. Identify the resident by facility policies and address them by name
6. Ask visitors to leave the room and inform them where they may wait
7. Provide privacy throughout procedure; pull curtains, shut door, properly cover patient as needed
8. Explain procedure to resident; speak clearly, slowly and directly to resident, maintaining face to face contact whenever possible
9. Answer resident’s questions about the procedure
10. Allow resident to assist as much as possible
11. Raise the bed to a comfortable working height
ENDING PROCEDURE ACTIONS
1. Position resident comfortably
2. Return bed to lowest position
3. Leave signal cord, telephone and water within reach
4. Perform a general safety check
5. Open curtains
6. Care for equipment following policy
7. Wash hands
8. Let visitors know they may return
9. Report completion of task & observation of any abnormalities and record actions and observations
REQUIRED
VITAL SIGNS
BLOOD PRESSURE
1. Clean ear pieces and diaphragm with antiseptic wipe
2. Position residents arm resting on firm surface with palm up
3. Wrap cuff around arm with bladder over artery 1” above antecubital space- cuff even and snug.
4. Place ear pieces in ears (directed forward towards eardrum) and place the diaphragm over artery
5. Inflate cuff to no more than 180mm/Hg or may use pulse obliteration method, candidate choice
6. Deflate cuff, note systolic reading, and note point of diastolic reading
7. Accurate reading within 4mmHg window on both systolic & diastolic
8. Accurately record blood pressure
TEMPERATURE (Tympanic, Oral or Axillary with electronic thermometer) (Examiners choice)
Tympanic:
1. Place tympanic thermometer cover on
2. Ask person to turn his head so ear is in front of you, put new probe cover on
3. Pull back on the ear (gentle, firm) to straighten the ear canal and insert probe gently into ear canal directed toward nose
4. Start the thermometer
5. Wait until you hear a beep or flashing light and remove
6. Read the temperature and record accurately
Oral/Axillary-
1. Ask the person if they have eaten or consumed a beverage, cold or hot or smoked within the last 15 minutes.
2. Place a sheath on the probe
3. Correct placement for obtaining oral reading or axillary reading
4. If necessary, hold the probe in place for oral
5. Leave the probe in place until the instrument beeps
6. Remove the probe sheath from the probe and dispose of properly
7. Replace the probe
8. Read the temperature and record accurately
RADIAL or APICAL PULSE
1. Locate pulse at the correct site
2. Count pulse for 30 sec. and double or count for 1 full min. accuracy within + or – 4 beats per minute
3. Document accurately
RESPIRATORY RATE
1. Count respirations for 30 sec. and double or count for 1 full min. Accuracy within + or - 2 breaths
2. Document Accurately
REQUIRED
HANDWASHING
1. Don’t touch the sink with your uniform
2. Turn water to warm
3. Wet and soap hands
4. Wash hands with fingers down for 15-30 seconds, including wrist, nails and between fingers
5. Rinse with fingertips down
6. Use dry paper towel to dry hands
7. Use a paper towel to turn off faucets
8. Immediately discard paper towels in trash without touching to your other hand
****You will be asked to complete 5 of the following:
SKILL 1
PRESSURE ULCER PREVENTION
1. Demonstrate 2 ways to prevent pressure ulcers:
For example:
a. Proper use of bed cradle
b. Elbow/heel protector
c. Using pillows to reduce skin to skin contact
d. Making sure sheets are wrinkle free
2. Explain 2 other ways to prevent pressure ulcers
For example:
a. Changing position frequently
b. Good nutrition and hydration
c. Provide good perineal care (keep resident clean and dry)
d. Be careful of the resident’s skin (no shearing or friction)
e. Check resident’s skin carefully-provide good skin care
f. Assist your resident to the bathroom frequently
g. Encourage mobility
h. Use pressure reducing devices
SKILL 2
POSITION FOLEY CATHETER/BAG/TUBING
1. Secure tubing to resident’s inner thigh or abdomen
2. Place tubing over leg
3. Position tubing to facilitate gravitational flow, no kinks
4. Attach to bed frame (not over or on side rail) always-below level of bladder
5. Keep catheter bag from touching floor
SKILL 3
OXYGEN
1. Demonstrate correct placement of O2 nasal cannula (place prongs following the contour of the nasal passage, tubing around ears and under chin (not behind head)
2. When asked by nurse-demonstrate how to check the oxygen flow meter and verbalize actions needed if flow rate is not accurate. Do not adjust the flow of oxygen-if incorrect, alert the nurse immediately
3. Verbalize 3 oxygen use guidelines
For Example:
a. Avoid lighting matches or smoking around oxygen use
b. Ensure that all electrical equipment is in good repair
c. No kinks in the tubing
d. Make sure the device is placed correctly on the resident
e. Do not remove the mask or nasal cannula, unless you are specifically told to do so by a nurse
f. Make sure the water level in the humidity bottle does not get too low
g. Provide oral care frequently
h. Watch for signs of skin irritation behind the person’s ears, over his or her cheeks, or around his or her ears and nose
i. Check to make sure oxygen is flowing
SKILL 4
OCCUPIED DRAW SHEET CHANGE
1. Place clean draw sheet on clean surface within reach (chair, over-the-bed table)
2. Provide privacy throughout procedure
3. Lower head of bed, placing resident in supine position
4. After raising side rail, assist resident to turn onto side, moving toward raised side rail
5. Loosen draw sheet, roll soiled draw sheet toward resident
6. Place and tuck in clean draw sheet on working side (this must be done before turning resident)
7. Raise side rail and assist resident to turn onto clean draw sheet
8. Remove soiled linens/draw sheet, avoiding contact with clothes, and place in appropriate location within room –never on floor
9. Pull and tuck in clean draw sheet, finishing with sheet free of wrinkle
SKILL 5
APPLY COLD COMPRESS
1. Cover cold compress with towel or other protective cover (compress should not be placed on bare skin without covering)
2. Properly place on correct site as directed by skills examiner
3. When asked by examiner, verbalize frequency of checks and how long you would leave compress on resident (initially check after 5 minutes/do not leave on resident for more than 20 minutes)
4. Assess for redness, swelling, irritation and or pain if this occurs remove compress and report to nurse immediately
SKILL 6
MEASURE AND RECORD FLUID INTAKE
1. Calculate intake in mL
2. Measure on a flat, level surface
3. Record intake accurately within +/- 25 mL's of nurses reading
SKILL 7
CONVERTING OUNCES TO ML’S- 30 mL’s = 1 ounce
1. Convert ounces to mL
2. Record amount accurately within +/- 25 mL's of nurses reading
SKILL 8
MEASURE/RECORD URINE OUTPUT
1. Place container on flat surface, measure accurately in mLs
2. Dispose of properly into toilet
3. Rinse and dry container
4. Remove gloves, wash hands
5. Record output accurately within +/- 25 mL's of nurses reading
SKILL 9
CONSCIOUS CHOKING
1. Candidate is able to identify symptoms of choking, asks resident “Are you choking?”
2. Call for help
3. Stands behind resident and wraps arms around resident’s waist
4. Places the thumb side of the fist against the resident’s abdomen
5. Positions fist slightly above navel
6. Grasp fist with other hand, press fist and hand into the resident’s abdomen with an inward, upward thrust
7. Candidate should indicate that they would repeat this procedure until it is successful or until the victim loses consciousness
SKILL 10
OBTAIN AND RECORD WEIGHT AND HEIGHT
WEIGHT
(Standing scale only)
1. Move weights to zero before assisting resident on to scale
2. Assist resident to stand on scale
3. Ensure resident is balanced and centered on the scale with arms at side
4. Accurately record weight within +/- 0.25 lbs. of nurse's measurement
HEIGHT
STANDING
1. Assist resident to stand on scales
2. Resident is balanced and centered on the scale with arms at side
3. Raise folded measuring bar above residents head, open and lower gently until bar rests on top of the head (not hair)
4. Accurately record height within +/- 0.5 inch of nurse's measurement
SKILL 11
APPLICATION OF ANTI-EMBOLISM STOCKINGS (TED hose)
1. Explain what position resident should be in when applying stocking- apply while resident is in bed or with feet elevated
2. Hold foot and heel of stocking and gather up stocking – turning the stocking inside out down to the heel, aids in application
3. Smooth up and over leg so hose is even, snug and not twisted or wrinkled
4. Heel and toe in proper location
5. The toe hole may be on the top or bottom of the toes, depending on the manufactures design
SKILL 12
PASSIVE RANGE OF MOTION 2 JOINTS -Examiners choice
1. Exercise passively 2 joints
2. When asked by examiner, explain or demonstrate that you understand to never exercise past the point of pain or resistance
3. Provide support for joint
4. Avoid fast jerky movements; demonstrate flexion, extension, adduction, abduction and rotation if applicable
5. Repeat exercise at least 3 times or as ordered
SKILL 13
MOVING AND POSITIONING RESIDENTS -Examiners choice
With each of the above positions you must demonstrate:
· Raise side rail while turning patient except on side you are working on
· Demonstrate proper body mechanics
· Maintain residents proper alignment at all time, for all positions
1. Draw Sheet:
· Move using a draw sheet (2 persons): Provide support for resident’s head. Grasp rolled draw sheet near residents shoulder’s and hips
2. Fowlers:
· Position in Fowler’s (high Fowler’s is 60 -90 degrees; semi-Fowler’s is 30-45 degrees; knees may be elevated approximately 15 degrees
3. Supine:
· Position in supine, in proper anatomical alignment
4. Chair/Wheelchair:
· Position in chair or W/C: provide good alignment-upper body and head erect, back and buttocks against back of chair, feet flat on floor or on W/C footrests
5. Sims (Semi Prone):
· Position in Sims /Semi prone on the correct side as directed by examiner,
Left: Resident left side lying, right leg flexed, lower arm behind resident.
Right: Resident right side lying, left leg flexed, lower arm behind resident.
Provide good alignment. Place a pillow under the head, upper arm and flexed leg
6. Lateral: (Right or Left)
· Position lateral/side-lying on the correct side as directed by examiner. Provide good alignment. Place a pillow between legs, behind back and under arm
· Note: For enema position place resident in left Sims or left lateral position
SKILL 14
ASSISTING TO AMBULATE
Demonstrating proper use of gait belt
1. Resident should have footwear with non-skid soles
2. Sit resident up, allow to dangle
3. Apply gait belt properly around resident's waist; avoid restricting circulation or breathing, or injury to skin
4. Assist resident to stand while holding gait belt. Grasp the gait belt at each side, not the front. Do not allow resident to hold onto you around your neck while transferring
5. Maintain own body mechanics while assisting resident to stand
6. Walk at resident’s side or slightly behind (on weak side, if resident has a weak side)
7. Demonstrate proper use of assistive devices (walker, cane-should be place on resident’s strong side)
SKILL 15
PIVOT TRANSFER FROM A BED TO A WHEELCHAIR/ Demonstrating proper use of gait belt
1. Lock the bed wheels
2. Resident should have footwear with non-skid soles
3. Position wheelchair close to bed on residents’ strong side
4. Move or remove foot rests from wheelchair
5. Lock wheelchair brakes
6. Lower bed and rails
7. Sit resident up, allow to dangle
8. Apply gait belt properly around resident's waist; avoid restricting circulation or breathing, or injury to skin
9. Assist resident to stand while holding gait belt. Grasp the gait belt at each side, not the front. Do not allow resident to hold onto you around your neck while transferring
10. Maintain own body mechanics while assisting resident to stand
11. Transfer to the strong side by pivoting on the strong side toward the wheelchair, using proper technique
12. Position resident properly in wheelchair with residents hips against back of seat
13. Remove gait belt without harming resident
14. Place foot rests under residents’ feet
SKILL 16
FEEDING THE DEPENDENT RESIDENT
1. Check that the name and diet on the meal tray matches the name of resident receiving it
2. Positions the resident in an upright position. Minimum 60 degrees
3. Wash and dry resident's hands before feeding
4. If resident wears dentures check to make sure dentures are in
5. Protects clothing from soiling by using napkin, clothing protector, or towel
6. Describes the foods being offered to the resident and maintain eye level contact while feeding resident
7. Offer fluid frequently
8. When asked by examiner, explain the pace and amount when feeding resident (offer food in small amounts, allow resident to chew and swallow)
9. Wipe resident's hands and face during meal as needed
10. When asked by examiner verbalize need to stop feeding when complications occur and report to nurse
For Example:
a. Choking
b. Persistent coughing
c. Mouth sores
d. Drooling
e. Cyanosis
f. Difficulty swallowing
11. Leave resident clean and in a position of comfort
SKILL 17
DENTURE CARE
1. Before handling dentures, protect dentures from possible damage (line the bottom of the sink with a towel/ washcloth or fill with water)
2. When asked by examiner, explain that water for cleaning dentures should be lukewarm (not hot or cold)
4. Brush dentures under running water with brush and paste provided
5. Place dentures in denture cup with water, adding cleaning tablet (if available), and cover with lid and allow to soak
6. Perform mouth care while dentures are out of the mouth
SKILL 18
LOG ROLLING RESIDENT WITH HIP FRACTURE PRECAUTIONS
1. Use at least 2 persons
2. Lower head of bed as flat as possible
3. Do not roll resident onto injured side
4. Place abduction splint or pillows between legs to support hip
5. On the count of “three” roll person in a single movement, being sure to keep the person’s head, spine and legs aligned
SKILL 19
ORAL CARE FOR AN UNCONSCIOUS RESIDENT/ASPIRATION PRECAUTIONS
1. Verbalize frequency of oral care (every 2 hours)
2. Place towel or drape under the resident’s head
3. Position resident (as resident’s medical condition indicates) to prevent aspiration:
a. Position resident in supine position with head to side or side lying (lateral) to prevent
aspiration or with HOB elevated and head turned to side, as resident’s medical condition
indicates
4. Insert swab/sponge tip gently into resident’s mouth
5. Do not use toothpaste/toothbrush unless approved by nurse
6. Rotate against all tooth surfaces, mucous membranes and tongue
7. Clean resident’s lips
8. Moisturize lips
9. Report abnormalities such as bleeding gums
SKILL 20
BACK RUB/MASSAGE
1. Place resident in a sitting or lateral position
2. Pour small amount of lotion into palm of hand and rub hands together to warm lotion
3. Apply with gentle pressure, using both hands from buttocks to back of neck without pulling skin, using long firm strokes
4. Use short circular strokes across the shoulders using both hands
5. Perform backrub for 3-5 min. or as ordered
6. Asses skin condition
7. Remove excess lotion
8. When asked by examiner, verbalize actions needed if redness or skin break down are noticed. Do not rub reddened area and report immediately to nurse
SKILL 21
FOOT/TOENAIL CARE
1. Inspect for cracked, broken nails/skin and between toes
2. Do not clip toenails
3. Soak feet in warm water
4. Dry feet completely including between toes
5. Apply lotion if desired but not between toes
6. Apply socks/shoes
7. Report abnormalities
SKILL 22
DRESSING/UNDRESSING RESIDENT (Must dress and undress)
1. Demonstrate how to properly dress/undress resident with hemiplegia
2. Provide privacy during entire procedure
3. Dress weak side first
4. Undress weak side last
SKILL 23
SHAVING WITH RAZOR BLADE
1. Place towel to protect resident’s clothing
2. Soften beard with warm washcloth and apply shaving cream
3. Gently pull skin taut
4. Use short strokes of razor in the direction the hair is growing
5. Rinse razor often
6. Rinse and dry resident’s face
7. Apply after shave if desired
8. Dispose blade in sharps container
SKILL 24
PROVIDE PERI-CARE (male or female examiners choice)
FEMALE
1. Assist resident in removing clothing, only as necessary, exposing only area being washed. Provide privacy (remembering dignity)
2. Obtain bath basin with water of a safe and comfortable temperature
3. Apply appropriate cleanser preferred by resident to wash cloth
4. Separate the labia, clean inside the labia downward from front to back (clean to dirty). Then wash the outside of the labia from front to back starting outside the labia and then going to the inside of the thighs. Repeat until the area is clean, using a different part of the wash cloth for each stroke
5. Rinse and gently dry each area thoroughly after washing
6. Turn the resident on their side
7. Clean the anal area from front to back
8. Rinse and gently dry each area thoroughly after washing
9. Redress resident
MALE
1. Assist resident in removing clothing, only as necessary, exposing only area being washed. Provide privacy (remembering dignity)
2. Obtain bath basin with water of a safe and comfortable temperature
3. Apply appropriate cleanser preferred by resident to wash cloth. Cleanse the penis from tip to base (clean to dirty). Repeat until the area is clean, using a different part of the wash cloth for each stroke
a. If male is uncircumcised retract the foreskin by gently pushing the skin toward the base of the penis and clean as directed above. Replace foreskin after drying thoroughly
4. Rinse and gently dry each area thoroughly after washing
5. Turn the resident on their side
6. Clean the anal area from front to back
7. Rinse and gently dry each area thoroughly after washing
8. Redress resident
SKILL 25
ASSISTING WITH A BEDPAN/FRACTURE PAN
1. Positions the bedpan/fracture pan under the resident correctly (If using a fracture pan, the flat side should be toward the back of the resident)
2. Raises head of bed to a comfortable level
3. Place tissue within reach of resident
4. Position call light within reach of the resident
5. Provide privacy
6. Gently removes bedpan
7. Provide or assist with peri-care as needed
8. Empty bedpan in toilet
9. Rinse, dry and store bedpan in proper location
10. Washes/assists resident to wash and dry hands
11. Record results accurately
SKILL 26
COLLECTING A STOOL SPECIMEN
1. Properly fill out label given and place on specimen container
2. Using a tongue depressor take a sample of feces from the bedpan or specimen collection device
3. Note color, amount and quality of the feces
4. Dispose of tongue depressor in a disposable bag
5. Empty remaining contents of bedpan or specimen collection device into toilet
6. Put lid tightly on the specimen cup
7. Place specimen cup into transport bag
8. Wash hands
9. Take the specimen cup to the designated location
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