NCLEX: Clinical Skills Performance Checklists

This chapter reviews the clinical skills most likely to be required in the clinical performance portion of the certification examination, the Clinical Skills Test (CST). Content includes principles of safe practice, the steps needed to perform each skill as well as exam alerts you need to recall when answering questions regarding nursing skills on the written examination (WE).

You observe principles of safe practice in providing both indirect and direct care during the CST.

Indirect Care: Represents performance that is a part of every skill; that is, hand washing, ensuring the resident’s privacy and comfort, resident rights, safety, and standard precautions (infection control and recording/reporting). You receive a separate score for these skill requirements. The evaluator observes your indirect care performance according to the following checkpoints, or critical steps, throughout each skill:

  • Wash hands before and after each nursing procedure, and between direct care given to each resident.
  • Greet resident, address by name, and introduce self.
  • Provide explanations to resident before beginning and throughout the procedure.
  • Provide privacy for the resident: Close door or cubicle curtain and protect body from undue exposure.
  • Promote resident safety: Identify resident; position to protect from falling; use assistive devices as needed; ensure all equipment is in proper working order; lock wheels of bed, wheelchair, stretcher, or other equipment with wheels when transferring resident from one area to another; remain with the resident throughout the procedure to protect from injury; leave call light within easy reach of the resident when leaving the resident’s room; provide instructions for postprocedure care as needed to ensure resident safety.
  • Promote resident rights: right to information regarding purpose of the procedure and findings as needed; dignity as well as observing the resident’s right to refuse the procedure.
  • Use standard precautions; unless otherwise noted, remove your gloves before recording the procedure.
  • Assemble all supplies at the bedside.

NOTE:

If gloves are to be removed and reapplied during the procedure, the action is included in the steps of the skill.

  • Promote resident comfort: Position, adjust room temperature, remove noxious odors as soon as possible, and so on.
  • Record the procedure, results, and resident’s response on the required form.
  • Report any abnormal results, changes in resident’s condition or problems encountered during the procedure to the nurse immediately.
  • Clean and store equipment, and ensure it is in working order.
  • Replenish bedside supplies and keep the work area and resident’s room tidy.

Direct Care: Refers to the particular steps of each separate skill reviewed in the following section. For example, indirect care guidelines related to measuring the radial pulse are the same as for all the skills listed in this chapter. However, the steps for measuring the pulse are different from those involved in measuring the resident’s temperature, for example. The evaluator observes and compares the direct care you provide the actor/client to the checkpoints that comprise each skill.

Please review the following checklists for the nursing skills you might be required to perform, and practice them until you feel proficient, paying particular attention to the checkpoints— critical steps listed in each skill because they might be weighted by the evaluator according to how critical each checkpoint is to the safety of the client.

EXAM ALERT
Indirect care checkpoints are included in each skill but are not repeated throughout the documentation of each skill to avoid redundancy. In preparing for the CST, include the indirect skill standards each time you review the skill to reinforce their importance. Checkpoints are likely to be asked on the written examination. Written Exam alerts (the icon that looks like a book) are highlighted here for your review as well.

Clinical Skills Performance Checklists: Hand washing

Focus topic: Clinical Skills Performance Checklists

EXAM ALERT
Your handwashing skill is evaluated at the beginning of the clinical examination. You are not prompted to wash your hands with each procedure that follows because the evaluator expects you to know to wash your hands before and after physical contact with the resident. Handwashing is considered part of indirect care, that is, standard precautions.

Checkpoint—Critical Step:

  • Wet hands with warm water and apply soap.
  • Work up lather cleansing front and back of hands, wrists, between fingers, around cuticles, and under nails.
  • Apply friction for a minimum of 15 seconds (as long as it takes to sing “Happy Birthday”).
  • Keeping fingers lower than wrist, remove all soap.
  • Dry hands with paper towel and limit contact of towel to cleansed hands; turn off water with paper towel and dispose of it.
  • Complete skill without contaminating hands.

Clinical Skills Performance Checklists: Measuring Body Temperature

Focus topic: Clinical Skills Performance Checklists

Obtain temperature reading per method used as documented in the sections that follow.

Clinical Skills Performance Checklists: Oral Temperature Measurement with Electronic Monitor

Focus topic: Clinical Skills Performance Checklists

  • Remove thermometer pack from charger and attach oral probe to thermometer.
  • Slide disposable plastic probe cover over thermometer probe until the cover stays in place.
  • Ask resident to open mouth; gently place thermometer probe under side of the tongue to the back of the mouth.
  • Ask resident to close mouth around probe with lips closed.
  • Remove probe when you hear an audible beep and see the temperature display on the thermometer.
  • Push ejection button on thermometer to discard plastic probe cover into appropriate receptacle.
  • Return thermometer probe to recording unit.
  • Return thermometer to the charger.

Clinical Skills Performance Checklists: Rectal Temperature Measurement with Electronic Thermometer

Focus topic: Clinical Skills Performance Checklists

  • Raise side rail and place resident in Sim’s (left sidelying) position.
  • Expose buttocks, keeping rest of body covered.
  • Remove thermometer pack from charger and attach rectal probe to thermometer.
  • Slide disposable plastic probe cover over thermometer probe until the cover stays in place.
  • Dip probe into liberal amount of lubricant applied to a tissue, covering the probe at least 1 to 2 inches.
  • With non-dominant hand, separate buttocks to expose anus; ask the resident to breathe slowly and relax.
  • With dominant hand, insert thermometer probe gently into anus, aiming the probe in the direction of the umbilicus, which is 1–2 inches; DO NOT FORCE the probe. If you feel resistance with the probe, withdraw it and notify the nurse.
  • Gently hold thermometer probe in place and remove it when you hear an audible beep and see the temperature display on the thermometer.
  • Push ejection button on thermometer to discard plastic probe cover into appropriate receptacle.
  • Return thermometer probe to recording unit.
  • Wipe the charger and probe with alcohol daily.
  • Return thermometer to the charger.
  • Wipe resident’s anal area with tissue to remove lubricant or feces, and discard the tissue in a biohazardous receptacle.

Clinical Skills Performance Checklists: Axillary Temperature with Electronic Thermometer

Focus topic: Clinical Skills Performance Checklists

  • Remove thermometer pack from charger and attach oral probe to thermometer.
  • Slide disposable plastic probe cover over thermometer probe until the cover stays in place.
  • Raise resident’s arm away from torso.
  • While holding thermometer horizontal to the resident’s axilla, insert thermometer probe into center of axilla, lower arm over probe, and place arm across resident’s chest.
  • Remove the thermometer probe when you hear an audible beep and see the temperature
    display on the thermometer.
  • Push ejection button on thermometer to discard plastic probe cover into appropriate receptacle.
  • Return thermometer probe to recording unit.

Clinical Skills Performance Checklists: Tympanic Membrane Temperature with Electronic Thermometer

Focus topic: Clinical Skills Performance Checklists

  • Request the resident to position head to one side away from you.
  • Note if there is cerumen (earwax) visible in the ear canal opening; do not attempt to remove cerumen from inside the outer ear canal.
  • Remove hand-held thermometer unit from charger.
  • Apply speculum cover over the tip of the unit (speculum), twisting the cover until it is securely in place.
  • Gently pulling ear pinna (soft lower tip of the ear) up and outward, insert speculum (tip of the thermometer unit) into the ear canal opening until it fits snugly into the canal.
  • Leaving speculum in place, depress the thermometer button to measure the temperature.
  • Leave speculum in place until you hear an audible signal and see the temperature measure on the digital display.
  • Gently remove the speculum.
  • Push ejection button on thermometer to discard plastic speculum cover into appropriate receptacle.
  • Return thermometer to charger.

Clinical Skills Performance Checklists: Measuring the Radial and Apical Pulse

Focus topic: Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Radial Pulse

Focus topic: Clinical Skills Performance Checklists

Checkpoint—Critical Step:

  • Place resident in the supine or sitting position.
  • If the resident is lying supine, place arm straight at side or fold arm over chest; if sitting, support arm with your arm or place on flat surface.
  • Place fat pads (just below finger tip) of first two fingers over groove along thumb (radial) side of resident’s wrist; slightly extend the wrist.
  • Lightly press against the radial bone until the pulse is absent momentarily, and then release pressure to feel the strongest pulse.
  • Determine the strength of the pulse: pounding-bounding (+4); strong (+3); weak (+2); thready (+1), or absent (0).
  • Count the pulse for 30 seconds; multiply the total count by 2.
  • If the pulse rate is irregular or less than 50 beats per minute (BPM), count the pulse for 60 seconds.
  • Record the rate, strength, and rhythm of the radial pulse on the facility form.

EXAM ALERT
A pulse rate less than 50–60 can indicate a serious condition and should be reported to the nurse immediately.

Clinical Skills Performance Checklists: Apical Pulse

Focus topic: Clinical Skills Performance Checklists

  • Clean earpieces and diaphragm of stethoscope.
  • Assist resident to supine or sitting position. Expose sternum (breastbone) and left side of chest.
  • With two or three fingers of your hand, locate the point of maximum intensity (PMI or apical pulse) of the heartbeat on the left chest wall.
  • Place the diaphragm of stethoscope over PMI and auscultate (listen) to the heartbeat for 30 seconds and multiply the count by 2; if the pulse is irregular, listen for 60 seconds.
  • Reposition resident’s gown or clothing over chest area and clean ear pieces and
    diaphragm of stethoscope.
  • Record the rate, strength, and rhythm of the apical pulse on the facility form.

Clinical Skills Performance Checklists: Measuring the Respirations

Focus topic: Clinical Skills Performance Checklists

  • Place resident in supine or sitting position; be sure you can view the chest.
  • Place resident’s arm across the chest comfortably, keeping your hand on the chest or the upper abdomen.
  • While talking to the resident to provide distraction, observe complete respiratory cycle (one inspiration and one expiration); while watching the sweep hand on your watch, count respirations for 30 seconds; multiply the count by 2.
  • If the respirations are irregular, count them for 60 seconds.
  • Record respiratory effort (unlabored to labored), depth (shallow to deep), and rate on the facility form.

Clinical Skills Performance Checklists: Blood Pressure

Focus topic: Clinical Skills Performance Checklists

  • Position the resident in supine or sitting position; if the resident has been active, wait at least five minutes before measuring the blood pressure.
  • Select proper size blood pressure cuff (sphygmomanometer). The cuff should fit 40% of the upper arm (if cuff is too small, the reading will be falsely high; if too large, the reading will be a false low reading).
  • Locate brachial artery (in bend of elbow on the side closest to the resident).
  • Place the cuff snugly around the upper arm approximately two-finger widths above the elbow.
  • Position the resident’s arm at the level of the heart if sitting or at the resident’s side while lying.
  • If a dial is connected to the cuff, place the cuff so the dial is easily seen.
  • Place the bell of the stethoscope diaphragm over the brachial artery and hold snugly with the fingers of your non-dominant hand; avoid touching the resident’s clothing or blood pressure cuff with the stethoscope.
  • Close valve of the cuff pump clockwise until tight.
  • Quickly inflate the cuff (around 8 seconds) to within 30 mmHg above estimated systolic pressure.
  • Slowly release pressure valve deflating the cuff, and allow needle of manometer gauge to fall at the rate of 2 to 3 mmHg/second.
  • Listen for the first clear sound and the point on the gauge at which you heard the
    first sound. If you become distracted and miss the point on the gauge where the first sound was heard, slowly and completely remove the cuff; wait at least one minute and repeat the procedure.
  • Continue to slowly deflate the cuff, noting the point at which the muffled sound completely disappears.
  • Listen as the needle moves 10 to 20 mmHG beyond last sound and allow cuff to completely deflate.
  • Remove cuff and return resident to comfortable position.

NOTE:

If measuring the blood pressure for the first time, measure the blood pressure in both arms and record the second set of measurements as the baseline. For subsequent measurements, use the arm with the highest initial reading. Avoid taking the blood pressure in the affected arm of the resident who has had a mastectomy or the arm in which a dialysis shunt is located.

Clinical Skills Performance Checklists: Partial Bedbath

Focus topic: Clinical Skills Performance Checklists

  • Check to be certain water is at a safe and comfortable temperature.
  • Drape resident so that only the area of the body being bathed is exposed.
  • Use washcloth without soap to cleanse the face.
  • Wipe eyes from inner canthus (side of eye closest to the nose) to the outer canthus (side of eye closest to the ear); change to a clean area of washcloth before cleansing other eye.
  • Pat face dry.
  • Protect bedding by repositioning towel under resident while bath procedure is in progress.
  • Using small amount of soap on washcloth, wash neck, hands, arms, and chest.
  • Dry neck, hands, arms, and chest.
  • Assist resident to turn safely to the side; wash, rinse, and dry back.
  • Warm lotion between your hands; apply lotion to the resident’s back.
  • Provide backrub from base of spine up to neck and shoulders using gentle, circular strokes.
  • Replace gown without exposing resident and secure.
  • If resident can wash perineal area, provide clean, warm water (no warmer than 115°F), soap, and cloths for washing and drying.
  • If resident is unable to finish the bath, change into clean gloves and provide perineal care or areas that the resident cannot reach. Review the perineal care skill in this chapter for details.
  • Lower the bed position and raise the side rails per facility policy.

Clinical Skills Performance Checklists: Perineal Care of the Female Resident

Focus topic: Clinical Skills Performance Checklists

  • Prepare a basin with comfortable, safe water temperature and place at the bedside.
  • Using a soapy washcloth, cleanse the genital area (urinary meatus, vulva, and perineum), washing from front to back, beginning over the urinary meatus (opening to allow voiding).
  • Using a different portion of the washcloth for each stroke, wipe each side of the vulva (area around the vaginal opening).
  • Cleanse the perineum (from bottom of vaginal opening to anus) from top to bottom.
  • Using a fresh washcloth for rinsing, completely remove all soap from the genital
    area.
  • Dry the perineal area from front to back.
  • Replace the water if it becomes cold or soapy.
  • Place the resident on side for cleansing of buttocks and rectal area.
  • Thoroughly rinse and dry buttocks and rectal area.
  • Place dry pad underneath resident when procedure is complete.
  • Clean and store equipment and leave work area tidy.
  • Report your observations, noting any redness, irritation, discharge, or pain in the perineal or buttocks area.

Clinical Skills Performance Checklists: Nail Care (Fingers and Toes)

Focus topic: Clinical Skills Performance Checklists

  • Soak nails in warm water at safe, comfortable temperature for 10–20 minutes before cleaning under the nails.
  • Use orangewood stick or wooden end of a cotton swab to remove debris from under the nails.
  • Dry resident hands or feet after soaking.
  • Keep nail edges smooth; using nail clippers, trim nails straight across and even with end of finger or toes; for residents with circulatory problems (for example, diabetes or Raynaud’s disease), trim nails as ordered.
  • Apply lotion to resident hands or feet after nails are manicured; do not apply lotion between toes.
  • Clean and store equipment and leave work area tidy.
  • Report any breaks in skin to the nurse.

Clinical Skills Performance Checklists: Mouth (Oral) Care

Focus topic: Clinical Skills Performance Checklists

  • Position resident in Fowler’s position.
  • Protect clothing from accidental spills.
  • Moisten toothbrush with water and apply toothpaste.
  • Brush all surfaces of teeth, sides of the tongue, and gums with gentle motions.
  • Offer resident the opportunity to rinse mouth or, if unconscious or unable to rinse mouth, apply mouthwash with a swab to gums, tongue, and mucous membranes in the mouth.
  • Dry lips and area around mouth.
  • Report any bleeding or presence of lesions (sores) of the mouth to the nurse.

Mouth (Oral) Care: Care of Dentures

Focus topic: Clinical Skills Performance Checklists

  • Keep dentures in a denture cup or emesis basin for transport to the sink for cleansing.
  • To reduce the risk for denture breakage, fill the sink with water or pad it with a paper towel.
  • Using cool or tepid running water, hold the dentures over the sink and thoroughly
    clean and rinse them.
  • Store clean dentures in denture cup filled with clean cool or tepid water.
  • Using a toothbrush or swab, provide mouth care to resident.
  • Offer resident the opportunity to rinse mouth.
  • Don clean gloves and inspect the inside of the mouth for lesions, redness, or sore areas.
  • Report any redness, irritation, sores, or pain in the resident’s mouth.

Clinical Skills Performance Checklists: Dressing

Focus topic: Clinical Skills Performance Checklists

  • Encourage resident to choose clothing to wear.
  • Collect all garments before removing gown or soiled clothing.
  • If one side of body is weak or paralyzed, support affected arm/side while undressing and dressing.
  • Remove gown or soiled garment from affected arm last.
  • Gather sleeve in hands and ease over affected arm.
  • Assist resident to don pants, shirt with sleeves, and socks.
  • Move extremities gently, being careful not to overextend or force extremities when undressing and dressing.
  • Adjust garments for comfort, alignment, and neat appearance.
  • Place soiled garments in hamper.

Clinical Skills Performance Checklists: Applying Elastic Support Hose

Focus topic: Clinical Skills Performance Checklists

  • Apply the support hose to clean legs while resident is lying in bed.
  • Holding the heel of the stocking, gather the rest of the stocking in your hand.
  • Support the resident’s foot at the heel.
  • Slip the front of the stocking over the toes, and then the foot before the heel.
  • Pull the stocking up smoothly over the leg.
  • Keep hose straight and wrinkle-free.
  • Remove the hose at least twice daily (once for bathing), and inspect the feet and legs for edema or reddened areas.
  • Report any signs of poor circulation or discomfort to the nurse.

Clinical Skills Performance Checklists: Making an Occupied Bed

Focus topic: Clinical Skills Performance Checklists

  • Check care plan for any precautions needed in moving and positioning the resident.
  • Adjust bed height to comfortable working condition.
  • Lower the side rail on the side where you are working.
  • Loosen the top bed linens at the foot of the bed.
  • Remove the bedspread and blanket separately; if soiled, hold linen away from uniform and place in a linen hamper. Never place linen on the floor.
  • Cover resident with bath blanket: Place blanket over resident and, with the resident holding the blanket in place (if unable to hold, tuck the top edge under the resident’s shoulder), bring top sheet down to resident’s ankles and remove from the bed; place in hamper.
  • Checking to be certain side rail on opposite side of the bed is up, ask the resident to roll onto side facing away from you (if resident is unable to assist, ask a coworker to roll resident toward opposite side).
  • Loosen bottom sheet and pull sheet from head of the bed to the foot.
  • With seam side down (facing the mattress), fanfold the pull sheet toward the back of the resident and tuck just under the shoulders, back, and buttocks; proceed to fanfold the bottom sheet and tuck; follow with the mattress pad, if changing it.
  • Clean, disinfect, and thoroughly dry the exposed mattress surface, if soiled.
  • Apply clean linen to the exposed side of the bed, mattress first, placing the center creases lengthwise along the center of the bed and fanfold other half toward the resident; repeat the same maneuver with the bottom sheet, and then the pull sheet; smooth all linen surfaces on your side.
  • Assist the resident to roll toward you and remain positioned on the side facing you, explaining that the resident will feel a bump as he or she rolls over the linens in the bed.
  • Raise the side rail on your side of the bed and move to the opposite side.
  • Loosening linens, reach across bed toward the resident and remove soiled linens by folding them into a bundle with soiled side turned inward; place them in the linen hamper.
  • Clean, disinfect, and thoroughly dry the exposed mattress surface, if soiled.
  • Gently pull clean linens smoothly over edge of mattress from head to foot of the bed, beginning with bottom sheet, and then pull sheet.
  • Tuck edges of pull ends of fitted bottom sheet to fit under the mattress.
  • Grasp edges of pull sheet and, leaning backward with spine straight, pull sheet edges toward you and tuck them snugly under the mattress; smooth all surfaces.
  • Assist resident in returning to supine position.
  • Apply top sheet over bath blanket, placing the length of sheet over client with center crease in the middle of the bed; open the sheet from head to toe and, asking the resident to hold the top hem or tucking it under resident’s shoulder, remove bath blanket and place in linen hamper.
  • Tuck bottom edge of top sheet under the mattress; miter the corners.
  • Place blanket or spread over client in same manner as top sheet without the bath blanket in place; keep bottom long edge the same as the edge of the top sheet, usually 6–8 inches from the mattress edge.
  • Turn back top sheet to make cuff over top of the blanket or spread; smooth blanket or spread.
  • Raise the side rails per facility policy.
  • Supporting resident’s head, remove pillow and change pillow case; place soiled case in linen hamper; replace pillow to support/align neck and head and for comfort.
  • Place call light within easy reach.
  • Lower the bed position to its lowest level.
  • Remove all soiled linen from the room to designated collection area.
  • Report any reddened areas noted on skin while changing linens.

For all the following positions, move the resident in alignment for safe turning.

Clinical Skills Performance Checklists: Moving the Resident to the Side of the Bed

Focus topic: Clinical Skills Performance Checklists

  • Adjust the bed to a comfortable working height, as flat as possible, and lock the wheels.
  • Raise the side rail on the opposite side prior to lowering the side rail closest to you.
  • Stand with your feet apart (one foot in front of the other), back straight, and knees bent.
  • Cross the resident’s arms across the chest.
  • Place your arms under the neck and shoulders; move the area from the shoulders up to the head of the resident’s body toward you; shift your weight from one leg to another.
  • Place your arms under the resident’s waist and thighs; move the middle portion (torso) of the resident’s body toward you.
  • Place your arms under the resident’s legs and move the lower portion of the body toward you.
  • If leaving the resident in the changed position, support head and back with pillow.
  • Check the resident for comfort.
  • Lower the bed and raise the side rails, if ordered.
  • Place the call light within easy reach.

Clinical Skills Performance Checklists: Supine Position

Focus topic: Clinical Skills Performance Checklists

  • Position resident on the back with face up, arms at sides, and legs straight and slightly apart.
  • Provide pillows for head and neck support and comfort.

Clinical Skills Performance Checklists: Fowler’s Position

Focus topic: Clinical Skills Performance Checklists

  • Raise head of bed at least 30 degrees (low Fowler’s position) up to 90 degrees (high Fowler’s position).
  • Unless prohibited, raise the knee gatch of the bed to comfort level to keep knees flexed to prevent resident from slipping down in the bed.
  • Support arms as needed for comfort.
SCREENSHOT

Clinical Skills Performance Checklists: Lateral (Side-Lying) Position

Focus topic: Clinical Skills Performance Checklists

  • Raise the opposite side rail and lock the wheels.
  • Move the resident to the side of the bed nearest you.
  • Flex the resident’s distant arm from you next to the head and place the resident’s arm nearest you across the chest.
  • Cross the resident’s leg nearest you over the other leg at the ankle.
  • Place one hand on the resident’s shoulder and the other hand on the nearest hip.
  • Turn the resident away from you onto the side.
  • Use a positioning device-adding pillow under uppermost leg from knee to below foot.
  • Adjust resident’s arm and shoulder to avoid pressure.
  • Provide positioning device-adding pillow to support shoulder and arm.
  • Lower the bed and the side rail as ordered.
Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Sim’s Position

Focus topic: Clinical Skills Performance Checklists

The Sim’s position is the same as the lateral position but with the undermost arm positioned at the resident’s back.

Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Prone Position

Focus topic: Clinical Skills Performance Checklists

  • Position the resident on abdomen with face turned to one side; position arms straight or flexed upward toward the head.
  • Keep the bed as flat as possible.
Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Orthopneic Position

Focus topic: Clinical Skills Performance Checklists

  • Assist the resident to sit straight up or assume a sitting position on the side of the bed.
  • Place a pillow on the overbed table and move the table directly under the upper body of the resident.
  • Assist the resident to learn forward and place both arms, slightly bent, at the elbows, on the pillow for comfort.
Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Logrolling the Resident

Focus topic: Clinical Skills Performance Checklists

  • Using correct body mechanics, raise the side rails; raise the bed to a comfortable working position and lock the wheels.
  • Keeping the bed as flat as possible, lower the side rail on your working side.
  • Roll the pull sheet placed under the resident up close to the resident’s body.
  • Place a pillow between the resident’s knees.
  • Hold the pull sheet at the resident’s shoulders closest to you (the other nursing assistant holds the hip) and move the resident to your working side of the bed.
  • Raise the side rail closest to you; you and your assistant must move to the other side of the bed; stand at the resident’s shoulders; your assistant stands near the thighs.
  • Lower the side rail closest to you.
  • Working together, grasp the pull sheet at the resident’s shoulders and hips and, as the resident holds himself or herself stiffly, turn the resident in one smooth movement to keep the spine straight.
  • Place the resident in side-lying or Sim’s position.
  • Place pillow behind head and neck for resident comfort.
  • Lower the bed and raise the side rails, if ordered.
  • Place the call light within easy reach.
Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Assisting the Resident to Sit on the Side of the Bed

Focus topic: Clinical Skills Performance Checklists

  • Position the bed so that the resident’s feet can either touch the floor or a footstool.
  • Raise the side rail behind the resident.
  • Assist the resident to a sitting position.
  • Place one arm behind the resident’s neck and shoulders; place other arm under the resident’s knees.
  • Turn the resident toward you so his or her legs hang over the side of the bed.
  • Support the resident while he or she regains balance.
  • Stay with resident to support an upright position, keeping body in straight alignment.
  • Check pulse and respirations.
  • Allow the resident to remain in the dangling position for 15–20 minutes.
  • Return the resident to bed by reversing the process.

Clinical Skills Performance Checklists: Assisting the Resident to Transfer from the Bed to a Chair or Wheelchair

Focus topic: Clinical Skills Performance Checklists

  • Place the chair on the resident’s strong side.
  • If using a wheelchair, lock the wheels and fold the footrests to the outside of the chair.
  • Place the bed in the lowest position and lock the wheels.
  • If side rails are up, lower the one nearest you.
  • Assist the resident to put on nonskid shoes and a robe.
  • Assist the resident to sit on the side of the bed and dangle to ensure balance. If using a gait-transfer belt, apply it snugly around the waist with belt buckle in front.
  • With your arms under the resident’s axilla, assist the resident to push down on the mattress and, on the count of three, stand facing you, blocking the resident’s knees and feet with yours; if using a gait-transfer belt, grasp the belt from underneath at each side.
  • Taking small steps or turn together (pivot) to a position so that the resident’s back of the knees touches the front of the chair.
  • Ask the resident to grasp the arms of the chair or your forearms and, on the count of three, bend your knees and lower the resident into the chair.
  • Place the call light within the resident’s reach.
  • To assist the resident to transfer from a chair or wheelchair to a bed, simply reverse the preceding steps.

Clinical Skills Performance Checklists: Transferring the Resident from a Bed with a Mechanical Lift

Focus topic: Clinical Skills Performance Checklists

Clinical Skills Performance Checklists
  • Ask for assistance to operate the lift.
  • Gather the lift and all supplies at the bedside.
  • Wheel the lift into position with the foot extensions under the bed on the side where the chair is positioned.
  • Set the adjustable base at its widest setting to assure its stability. Lock the wheels of the lift.
  • Secure the lifting chains to handles on the side of the lift sling.
  • Place the lift sling under the resident, placing the narrow end at the top of the
    shoulders and the wider end to below the knees; center the resident’s body on the sling to provide for equal distribution of weight.
  • Move the lift arms directly over the resident and lower the horizontal bar by releasing the hydraulic valve; when the lift arms are in place, close the valve.
  • Attach the lift straps or hooks to the openings on the lift seat and gradually lift the resident above the bed surface.
  • As you continue to operate the lift, ask a coworker to guide the resident with his or her hands as the client is lifted, checking to be sure the sling is securely under the resident.
  • Move the client over the chair making certain that the hydraulic valve is CLOSED.
  • Releasing the hydraulic valve very slowly and smoothly, lower the client into the chair.
  • Secure the resident throughout the lift for protection and reassurance.
  • Following the lift into the chair, wheelchair, or stretcher, leave the sling under the resident for easy return to bed as ordered.
  • Apply seat belt or other restraint as needed.
  • Place the call light within easy reach.
  • When the resident returns to bed, follow the same process for operating the lift and, when the resident is positioned in bed, remove the sling.
  • Clean and store the lift per facility policy.

Clinical Skills Performance Checklists: Moving the Resident from a Bed to a Stretcher (Gurney)

Focus topic: Clinical Skills Performance Checklists

  • Ask for assistance from two or three coworkers.
  • Raise the bed to a comfortable working height and lock the wheels.
  • Remove the top linen and cover with a bath blanket; loosen the pull sheet.
  • If the side rail is up, lower it on your side.
  • Grasp the pull sheet at the resident’s shoulder’s waist; ask another coworker positioned next to you to grasp the sheet at the hips and thighs. In unison on the count of three, pull the resident toward you.
  • Position the stretcher against the side of the bed closest to you and lock the wheels.
  • With two other coworkers stationed on the other side of the bed, roll the edges of the pull sheet close to each side of the resident.
  • While two other coworkers steady the resident from the other side of the bed, in
    unison on the count of three, move the resident from the bed to the stretcher.
  • Position the resident in the center of the stretcher, support the head and shoulders with pillows if allowed, and secure the resident with safety straps and raise the side rails on the stretcher.
  • Unlock the wheels on the stretcher and transport the resident feet first with the help of another coworker.
  • Remain with the resident until relieved by another staff member.

Clinical Skills Performance Checklists: Using a Gait-Transfer Belt to Assist the Resident to Ambulate

Focus topic: Clinical Skills Performance Checklists

  • Apply the gait-transfer belt snugly around the resident’s waist, fastening the buckle in the front, slightly to the side and over the clothing as illustrated.
  • Stand directly in front of the resident with legs slightly apart.
  • While holding the gait-transfer belt with your hands, assist the resident to a standing position so that the resident’s feet are positioned between yours.
  • Transfer one of your hands to the side of the gait-transfer belt; move the other hand to hold the belt in the back.
  • To ambulate the resident, keep hands in current position and walk at the resident’s side and slightly behind him or her.
  • At the completion of the ambulation, return the resident to the chair or bed. If the
    resident begins to fall, do not attempt to prevent the fall but, with your feet wide apart to maintain your balance, bend your knees and lower the resident to the floor. Place your leg behind the resident, allowing the resident to rest his or her body against your leg and protect the head from injury. Stay with the resident; do not move him or her and call for assistance. Report the details to your supervisor and assist with completing an incident report.
Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Passive Range of Motion Exercises

Focus topic: Clinical Skills Performance Checklists

  • Raise the bed to a comfortable working height and lock the wheels.
  • Position the resident in the supine position with pillow under head.
  • Exercise each shoulder, rotating the shoulder joint smoothly; abduct and adduct the shoulder.
  • Supporting the wrist and elbow, exercise the elbow and forearm by flexing and extending the lower arm.
  • Rotate and flex the wrists, one wrist at a time, from side to side (ulnar deviation and radial deviation).
  • Flex and extend each hand at the wrist.
  • Flex and extend the fingers and thumb of each hand.
  • Exercising each leg at a time, support the foot from behind the ankles, and flex the lower legs by bending the knee.
  • Exercising each leg at a time, support each foot from behind the ankles, and adduct and abduct the legs at the hip.
  • Exercising each hip at a time, rotate each leg at the hip, supporting the ankle.
  • Supporting each foot behind the instep, rotate, flex, and extend the foot at the ankle.
  • Grasp, flex, and extend the toes.

CAUTION:

If the resident complains of sudden pain in the calf when performing steps 11 or 12, stop the procedure and notify the nurse because this could be a symptom of a blood clot in the lower leg.

Clinical Skills Performance Checklists: Applying Restraints

Focus topic: Clinical Skills Performance Checklists

1. Assemble appropriate type and size of restraint at the bedside.
2. Apply the selected restraint:

  • Safety Belt: Place the belt around the resident’s waist over the clothing; keep a
    finger’s width between the resident and the belt; fasten the belt at the back of the
    chair or, if applied on a stretcher, secure the belt firmly over the resident’s abdomen or hips; check facility policy for removal schedule.
  • Jacket Restraint: Place vest on resident with opening at the front or back
    (depending on the type); pull the tie on the end of the vest flap across the chest,
    through the slit in the opposite side of the chest; repeat for the other tie; use a
    half-bow knotto secure each tie around the movable bed frame (prevent tourniquet effect when resident moves but maintains safety) or behind the chair securing it to a chair leg (an alternative is to fasten the vest ties together behind the chair using a square knot); make sure that the resident can expand chest completely for breathing; check facility policy for restraint removal and reapplication schedule.
  • Mitt Restraint: Apply a commercial thumbless mitt to the hand to be restrained;
    ensure that the fingers can be slightly flexed and are free to move; follow manufacturer’s directions for securing the mitt; check facility policy for removal schedule.
  • Wrist or Ankle Restraint: Pad bony areas on wrist or ankle; apply padded portion of the restraint around the ankle or wrists; pull the tie of the restraint through the slit in the wrist portion or through the buckle; use a half-bow knot or square knot to attach the other end of the restraint to the movable portion of the bed (prevents tourniquet effect).

EXAM ALERT
Follow facility policy on frequency of checking on resident status while in restraints as well as removal schedule. Failure to follow policy could be considered negligence.

FURTHER READING/STUDY:

Resources:

 

 

 

 

 

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