1. Ask nurse about residents needs, abilities and limitations, if necessary.

Help

Options

focusNode

Didn't know it?
click below

Knew it?
click below

Don't Know

Remaining cards (0)

Know

retry

shuffle

restart

0:00

Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

Normal Size Small Size show me how

CNA Skill test

cna skills

Term	Definition
Initial Steps	1. Ask nurse about residents needs, abilities and limitations, if necessary.
	2. Knock before entering room
	3.Greet resident by name; check i.d.
	4. Introduce yourself(name, title.)
	5. Explain what you will be doing;Encourage resident to help as able.
	6. Gather supplies and check equipment. 7. Wash your hands.
	8. Close curtains,drapes,doors; keep resident coverd; expose only areas of body necessary to do procedure.
	9. Raise side rails before raising bed to comfortable height;usually waist high, lower side rail on side care is being given.
	10. Wear gloves as indicated by standart precautions.
	11. Use good body mechanics.
Final Steps	1. Use good body mechanics.
	2. Be certain resident is comfortable and in
	3. Lower bed height and position side rails as appropriate.
	4. Place call light and water within patients reach.
	5. Ask resident if anything else is needed.
	6. Thank resident.
	7. Remove supplies and clean equipment according to current nursing practices.
	8. Remove gloves if applicable and wash your hands.
	9. Open curtains, drapes and door according to residents wishes.
	10. Perform a safety check of resident and environment.
	11. Report unexpected findings to nurse. 12. Document procedures according to current nursing practices.
1. Use good body mechanics.
2. Be certain resident is comfortable and in good alignment.
3. Lower bed height and position side rails as appropriate.
4. Place call light and water within patients reach.
5. Ask resident if anything else is needed.
6. Thank resident.
7. Remove supplies and clean equipment according to current nursing practices.
8. Remove gloves if applicable and wash your hands.
9. Open curtains, drapes and door according to residents wishes.
10. Perform a safety check of resident and environment.
11. Report unexpected findings to nurse.
12. Document procedures according to current nursing practices

1. Wash hands (according to procedure 1).
2. Put on gloves.
3. Check for tears.
4. Perform procedure.
5. Remove one glove by grasping outer surface just below cuff.
6. Pull glove off so that it is inside out.
7. Hold the removed glove in your gloved hand.
8. Place two fingers of ungloved hands under cuff of other glove and pull down so first glove is inside second glove.
9. Dispose of gloves without contaminating hands.
10. Wash hands (according to procedure 1).
1. Do initial steps.	SUPINE POSITION
2. Lower head of bed.
3. Move resident to head of bed if necessary (according to procedure 8).
4. Position resident flat on back with legs slightly apart.
5. Align resident's shoulders and hips.
6. Use supportive padding if necessary.
7. Do final steps.
Procedure 4: Lateral Position:
1. Do initial steps.
2. Place resident in a supine position (according to procedure 3.)
3. Move resident to side of bed close to you.
4. Cross resident's arms over chest.
5. Slightly bend knee of nearest leg to you or cross nearest leg over farthest leg at ankle.
6. Place your hands under resident’s shoulder blade and buttock. Turn resident away from you onto side.
7. Place supportive padding behind back, between knees and ankles, and under top arm.
8. Do final steps.
Procedure 5: Fowler's Position:
1. Do initial steps.
2. Move resident to supine position (according to procedure 3).
3. Elevate bed 45 to 60 degrees.
4. Use supportive padding if necessary.
5. Do final steps.
Procedure 6: Semi-Fowlers:
1. Do initial steps.
2. Move resident to supine position (according to procedure 3).
3. Elevate head of bed 30 to 45 degrees.
4. Use supportive padding if necessary.
5. Do final steps.
Procedure 7: Sit On Edge of Bed:
1. Do initial steps.
2. Adjust bed height to lowest position.
3. Move resident to side of bed closest to you.
4. Raise head of bed to sitting position, if necessary.
5. Place one arm under resident's shoulder blades and the other arm under resident's thighs.
6. On count of three, slowly turn resident into sitting position with legs dangling over side of bed.
7. Support for 10 to 15 seconds, check for dizziness.
8. Assist resident to put on shoes or slippers.
9. Move resident to edge of bed so feet are flat of floor.
10. Do final steps.
Procedure 8: Assist Resident to Move to Head of Bed:
1. Do initial steps.
2. Lower head of bed and lean pillow against head board.
3. Ask resident to bend knees, put feet flat of mattress.
4. Place one arm under resident's shoulder blades and the other arm under resident's thighs.
5. Ask resident to push with feet on count of three.
6. Place pillow under resident's head.
7. Do final steps.
Procedure 9: Protective Devices:
1. Do initial steps.
2. Apply vest according to manufacturer's directions.
3. Apply soft belt according to manufacturer's directions.
4. Fasten with quick release tie to moveable part of bed frame or kick spurs of wheel chair.
5. Place open hand flat between resident and protective device.
6. Do final steps.
7. Visit resident at least every hour and release protective device at least every two hours.
Procedure 10: Walking:
1. Do initial steps.
2. Assist resident to sit on edge of bed (according to procedure 7).
3. Assist resident to stand on count of three.
4. Allow resident to gain balance.
5. Stand to side and slightly behind resident.
6. Walk at resident's pace.
7. Do final steps.
Procedure 11: Assist With Walker: 1. Do initial steps.
2. Assist resident to sit on edge of bed (according to procedure 7).
3. Place walker in front of resident.
4. Have resident grasp both arms of walker.
5. Brace leg of walker with your foot and place your hand on top of walker.
6. Assist resident to stand on count of three.
7. Stand to side and slightly behind resident.
8. Have resident move walker ahead 6 to 10 inches then step up.
9. Do final steps.
Procedure 12: Assist to Chair:
1. Do initial steps.
2. Place chair on resident's unaffected side. Brace firmly against side of bed.
3. Assist resident to sit on edge of bed (according to procedure 7).
4. Stand at resident's side.
5. Have resident grasp farthest arm of chair.
6. Tell resident to stand on count of three.
7. Help resident slowly turn and sit.
8. Check body alignment.
9. Do final steps.
Procedure 13: Transfer to Wheelchair and Transport:
1. Do initial steps.
2. Place wheelchair on resident's unaffected side. Brace firmly against side of bed with wheels locked and foot rests out of way.
3. Assist resident to sit on edge of bed (according to procedure 7).
4. Stand in front of resident and block resident's feet with your feet.
5. Place your hands under resident's arms and around resident's shoulder blades.
6. Ask resident to place his hands on your upper arms.
7. On the count of three, help resident into a standing position by straightening your knees.
8. Allow resident to gain balance, check for dizziness.
9. Move your feet 18 inches apart and slowly turn resident.
10. Lower resident into wheelchair by bending your knees and leaning forward.
11. Align resident's body and position foot rests.
12. Transport resident forward through open doorway after checking for traffic.
13. Transport resident up to closed door, open door and back wheelchair through doorway.
14. Take resident to destination and lock wheelchair.
15. Do final steps.
Procedure 14: Drape and Undrape:
1. Do initial steps.
2. To drape, unfold drape over top linen.
3. Ask resident to hold drape or tuck drape under resident's shoulders.
4. Roll top linen from beneath drape to foot of bed.
5. Perform procedure.
6. To undrape, cover resident with top linen.
7. Ask resident to hold top of linen or tuck under resident's shoulders.
8. Roll drape from under top linen to foot of bed and remove.
9. Do final steps.
Procedure 15: Rub Back:
1. Do initial steps.
2. Place resident onto side with back toward you.
3. Expose back and shoulders.
4. Rub lotion between your hands.
5. Make long, firm strokes along spine from buttocks to shoulders. Make circular strokes down on shoulders, upper arms and back to buttocks.
6. Repeat for at least 3-5 minutes.
7. Gently pat off excess lotion with towel. Cover and position resident as requests.
8. Do final steps.
Procedure 16: Heel or Elbow Protectors:
1. Do initial steps.
2. Check skin on resident's heels or elbows.
3. Report any unexpected findings to the nurse immediately.
4. Apply heel or elbow protectors according to manufacturer's directions.
5. Place width of two fingers between resident and protector.
6. Do final steps.
Procedure 17: Check Skin:
1. Do initial steps.
2. Drape resident (according to procedure 14).
3. Check bony areas including ears, shoulder blades, elbows, coccyx, hips, knees, ankles, and heels for redness and warmth.
4. Check friction areas including under breasts and arms, between buttocks, groin, thigh, skin folds, contracted areas, and around any tubing for redness, irritation, moisture and odor.
5. Undrape resident (according to procedure 14).
6. Report any unusual findings to the nurse immediately.
7. Do final steps.
Procedure 17: Oral Care:
1. Do initial steps.
2. Raise head of bed so resident is sitting up.
3. Put on gloves (according to procedure 2).
4. Drape towel under resident's chin.
5. Wet brush and put on small amount of toothpaste.
6. Brush upper teeth and then lower teeth.
7. Hold emesis basin under resident's chin.
8. Have resident rinse mouth with water and spit into emesis basin.
9. If requested, give resident mouthwash diluted with half water.
10. Check teeth, mouth, tongue, and lips for odor, cracking, sores, bleeding, and discoloration. Check for loose teeth. Report any unusual findings to nurse.
11. Remove towel and wipe resident's mouth.
12. Remove gloves (according to procedure 2).
13. Do final steps.
Procedure 18: Range of Motion:
1. Do initial steps.
2. Position resident in good body alignment.
3. Check joints. If swelling, redness or warmth is present, or if resident complains of pain, notify nurse. continue procedure only if instructed.
4. Support limb above and below joint.
5. Begin range of motion at shoulders and include the shoulders, elbows, wrists, thumbs, fingers, hips, knees, ankles, and toes.
6. Slowly move joint in all directions it normally moves.
7. Repeat movement at least five times.
8. Encourage resident to participate as much as possible.
9. Stop procedure at any sign of pain and report to nurse immediately.
10. Do final steps.
Procedure 19: Change Gown:
1. Do initial step.
2. Untie soiled gown.
3. Draw top sheet over resident's chest.
4. Remove resident's arms from gown, unaffected arm first.
5. Roll soiled gown from neck down and remove from beneath sheet.
6. Slide resident's arms into clean gown, affected arm first.
7. Tie gown.
8. Remove top sheet from beneath clean gown and cover resident.
9. Do final steps.
Procedure 20: Dressing a Dependent Resident:
1. Do initial steps.
2. Assist resident to choose clothing.
3. Move resident onto back.
4. Drape resident (according to procedure 14).
5. Guide feet through leg openings of underwear and pants, affected leg first. Pull garments up legs to buttocks.
6. Slide arm into shirt sleeve, affected side first.
7. Turn resident onto unaffected side. Pull lower garments over buttocks and hip. Tuck shirt under resident.
8. Turn resident onto affected side. Pull lower garments over buttocks and hip and straighten shirt.
9. Turn resident onto back and slide arm into shirt sleeve. Align and fasten garments.
10. Do final steps.
Procedure 21: Unoccupied Bed:
1. Collect clean linen in order of use.
2. Carry linen away from your uniform.
3. Do initial steps.
4. Place linen on clean surface (bed stand, over bed table, or back of chair).
5. Put bed in flattest position.
6. Remove pillowcase.
7. Loosen soiled linen. Roll linen from head to foot of bed and place in hamper/bag, at foot of bed or in chair.
8. Fanfold bottom sheet to center of bed and fit corners.
9. Fanfold top sheet to center of bed.
10. Fanfold blanket over top sheet.
11. Tuck top linen under foot of mattress and miter corner.
12. Move to other side of bed.
13. Fit corners of bottom sheet, unfold top linen, tuck it under foot of mattress and miter corner.
14. Fold top of sheet over blanket to make cuff.
15. Put on pillowcase and place at head of bed with open end away from door.
16. For open bed: make toe pleat and fanfold top linen to foot of bed with top edge closest to center of bed.
17. For closed bed: pull bedspread over pillow and tuck bedspread under lower edge of pillow. Make tow pleat.
18. Do final steps.
Procedure 22: Occupied Bed:
1. Collect linen in order of use.
2. Carry linen away from your uniform.
3. Do initial steps.
4. Place linen on a clean surface (bedside table, over bed table, or back of chair).
5. Lower head of bed.
6. Drape resident (according to procedure 14).
7. Turn resident away from you toward side rail.
8. Loosen bottom lines and roll linen toward resident tucking it snugly against resident's back.
9. Fanfold bottom sheet to center of bed and fit corners over mattress.
10. Turn resident onto back, raise side rail, move to other side of bed and lower side rail.
11. Turn resident away from you toward side rail.
12. Loosen soiled linen. Roll linen from head to foot of bed and place in hamper/bag, at foot of bed or in chair.
13. Unfold bottom sheet and fit corners over mattress.
14. Place resident in supine position and raise side rail.
15. Remove pillow, change pillowcase and place pillow under resident's head with open end away from door.
16. Place clean top sheet over resident and remove drape (according to procedure 14).
17. Unfold blanket over top sheet and make cuff.
18. Tuck top linens under foot of mattress and miter corners.
19. Loosen top linens over resident's feet.
20. Do final steps.
Procedure 23: Fingernail Care:
1. Do initial steps.
2. Check fingers and nails for color, swelling, cuts, or splits. Check hands for extreme heat or cold. Report any unusual findings to nurse before continuing procedure.
3. Raise head of bed so resident is sitting up.
4. Fill bath basin halfway with warm water and have resident check water temperature.
5. Soak resident’s hands and pat dry.
6. Put on gloves (according to procedure 2).
7. Clean under nails with orange stick.
8. Clip fingernails straight across, then file in a curve.
9. Remove gloves (according to procedure 2).
10. Do final steps.
Procedure 24: Safety Razor:
1. Do initial steps.
2. Raise head of bed so resident is sitting up.
3. Fill bath basin halfway with warm water.
4. Drape towel under resident's chin.
5. Put in gloves (according to procedure 2).
6. Moisten beard with washcloth and put shaving cream over area.
7. Hold skin taut and shave beard in downward strokes on face and upward strokes on neck.
8. Rinse resident's face and neck.
9. Apply after-shave lotion as requested.
10. Remove towel
11. Remove gloves (according to procedure 2)
12. Do final steps.
Procedure 25: Electric Razor:
1. Do initial steps.
2. Raise head of bed so resident is sitting up.
3. Do not use electric razor near any water source, when oxygen is in use or if resident has a pacemaker.
4. Drape towel under resident's chin.
5. Put on gloves (according to procedure 2).
6. Apply pre-shave lotion as resident wishes.
7. Hold skin taut and shave residents face and neck according to manufacturer’s guidelines.
8. Apply after-shave lotion as resident wishes.
9. Remove towel from resident.
10. Remove gloves (according to procedure 2).
11. Do final steps.
Procedure 26: Denture Care:
1. Do initial steps.
2. Raise head of bed so resident is sitting up.
3. Put on gloves.
4. Drape town under resident's chin.
5. Remove upper dentures by gently moving them up and down to release suction. Turn lower dentures slightly to lift out of mouth.
6. Put dentures in denture cup marked with resident's name and take to sink.
7. Line sinks with towel and fills halfway with water.
8. Apply denture cleaner to toothbrush.
9. Hold dentures over sink and brush all surfaces.
10. Rinse dentures under warm water, please in cup and fill with cool water.
11. Clean resident's mouth with swab if necessary. Help resident rinse mouth with water or mouthwash diluted with half water if requested.
12. Check teeth, mouth, tongue, and lips for odor, cracking, sores, bleeding, and discoloration. Check for loose teeth. Report any unusual findings to nurse.
13. Help resident place dentures in mouth if requested.
14. Remove gloves (according to procedure 2).
15. Do final steps.
Procedure 28: Oral Care for the Unconscious:
1. Do initial steps.
2. Drape towel over pillow.
3. Turn resident onto unaffected side.
4. Put on gloves (according to procedure 2).
5. Place an emesis basin under resident's chin.
6. Hold mouth open with padded tongue blade.
7. Dip swab in cleaning solution and wipe teeth, gums, tongue, and inside surfaces of mouth changing swab frequently.
8. Rinse with clean swab dipped in water.
9. Check teeth mouth, tongue, and lips for odor, cracking, sores, bleeding and discoloration. Check for loose teeth. Report any unusual findings to the nurse.
10. Cover lips with a thin layer of petroleum jelly.
11. Remove gloves (according to procedure 2).
12. Do final steps.
Procedure 29: Comb Hair:
1. Do initial steps.
2. Raise head of bed so resident is sitting up.
3. Drape towel over pillow.
4. Remove resident's glasses and any hairpins or clips.
5. Remove tangles by dividing hair into small sections and gently combing out from ends of hair to scalp.
6. Use hair preparations as resident wishes.
7. Style hair as resident wishes.
8. Offer mirror.
9. Do final steps.
Procedure 30: Assist to Eat: 1. Do initial steps.
2. Assist resident with elimination if necessary.
3. Assist resident to wash hands.
4. Help resident into a comfortable sitting position.
5. Check meal card for name and diet. Check tray for correct food, condiments, and utensils.
6. Serve any tray with main course closest to resident.
7. Offer resident napkin.
8. Cut and season food, butter bread, and open cartons as requested.
9. Check resident every 10-15 minutes.
10. Remove napkin and tray.
11. Assist resident to wash hands and face.
12. Measure and record intake if required.
13. Do final steps.
Procedure 31: Feeding:
1. Do initial steps.
2. Assist resident with elimination if necessary.
3. Assist resident to wash hands.
4. Place resident in a comfortable eating position.
5. Check meal card for name and diet. Check tray for correct food, condiments, and utensils.
6. Set tray on over bed table and describe food.
7. Place napkin or clothing protector under resident's chin and across chest.
8. Ask resident what food is preferred.
9. Fill spoon half full with food. Direct food to unaffected side of mouth.
10. Allow resident time to chew and swallow. Offer fluids as resident wishes.
11. Wipe resident's mouth as needed.
12. Remove napkin or clothing protector and tray.
13. Wash resident's hands and face.
14. Measure and record intake if required.
15. Do final steps.
Procedure 32: Shower:
1. Do initial steps.
2. Clean shower and shower chair.
3. Help resident remove clothing. Drape resident with bath blanket.
4. Turn on water and have resident check water temperature.
5. Assist resident into shower and lock wheels of shower chair.
6. Let resident wash as much as possible, starting with face.
7. Help resident shampoo and rinse hair.
8. Stay with resident during process.
9. Give resident a towel and assist to pat dry.
10. Assist resident out of shower.
11. Help resident dress, comb hair, and return to room.
12. Do final steps.
Procedure 33: Bed Bath:
1. Do initial steps.
2. Offer resident urinal or bedpan.
3. Drape resident (according to procedure 14).
4. Fill bath basin with warm water and have resident check water temperature.
5. If resident has open lesions or wounds, put on gloves (according to procedure 2).
6. Fold washcloth and wet.
7. Gently wash eye from inner corner out. Using a different part of cloth wash other eye.
8. Wet washcloth and apply soap, if requested. Wash, rinse, and pat dry face, neck, ears, and behind ears.
9. Remove resident's gown.
10. Place towel under far arm.
11. Wash, rinse, and pat dry hand, arm, shoulder, and underarm.
12. Repeat steps 10 and 11 with other arm.
13. Place towel over chest and abdomen, and lower bath blanket to waist.
14. Lift towel and wash, rinse, and pat dry chest and abdomen,
15. Pull up bath blanket and remove towel.
16. Place towel under far leg.
17. Wash, rinse, and pat dry leg and foot.
18. Repeat steps 16 and 17 with other leg and foot.
19. Change bath water.
20. Turn resident.
21. Wash rinse and pat dry from neck to buttocks including anal area.
22. Change bath water and gloves. Use clean washcloth and towel.
23. Provide perineal care (according to procedure 34, steps 8-13).
24. Help resident put on clean gown.
25. Do final steps.
Procedure 34: Perineal Care:
1. Do initial steps.
2. Offer resident a urinal or bed pan.
3. Assist resident to supine position (according to procedure 3).
4. Place waterproof pad under resident's hips.
5. Drape resident (according to procedure 14).
6. Fill wash basin with warm water and have resident check water temperature.
7. Put on gloves (according to procedure 2).
8. Assist resident spread legs and life knees if possible.
9. Wet and soap folded washcloth.
10. If resident has a catheter, check for leakage, secretions or irritations. Gently wipe four inches of catheter from meatus out.
11. Wipe from front to back and from perineum to thighs. Change washcloth as necessary
For females:
A: Separate Labia. Wash urethral area first.
B: Wash between and outside labia in downward strokes, alternating from side to side and moving outward to thighs. Use different part of washcloth for each stroke.
For males:
A: Pull back foreskin if male is uncircumcised. Wash and rinse the tip of penis using circular motion beginning at the urethra.
B: Continue washing down the penis to the scrotum and inner thighs.
12. Change water in basin. With a clean washcloth, rinse area thoroughly in the same direction as when washing.
13. Gently pat area dry in the same direction as when washing.
14. Assist resident to turn onto side away from you.
15. Wet and soap washcloth.
16. Clean anal area from front to back. Rinse and pat dry thoroughly.
17. Remove pad, assist resident to turn onto back and undrape resident (according to procedure 14).
18. Remove gloves.
19. Do final steps.
Procedure 35: Assist to Bathroom:
1. Do initial steps.
2. Walk with resident into bathroom.
3. Assist resident lower garments and sit.
4. Give resident call light and toilet paper.
5. If resident is able to be left alone, step out of bathroom and return when called.
6. Put on gloves (according to procedure 2).
7. Assist resident to wipe area from front to back.
8. Remove gloves (according to procedure 2).
9. Assist resident to raise garments.
10. Assist resident to wash hands.
11. Walk with resident back to bed or chair.
12. Do final steps.
Procedure 36: Bedside Commode:
1. Do initial steps.
2. Place commode next to bed on resident's unaffected side.
3. Assist resident to commode.
4. Give resident call light and toilet paper.
5. If resident is able to be left alone, step behind curtain and return when called.
6. Put on gloves (according to procedure 2).
7. Assist resident wipe from front to back.
8. Help resident into bed.
9. Remove and cover pan and take to the bathroom.
10. Check urine and/or feces for color, odor, amount and character and report ant unusual findings to nurse.
11. Dispose of urine and/or feces, sanitize pan and return pan to current nursing practices.
12. Remove gloves (according to procedure 2).
13. Assist resident to wash hands.
14. Do final steps.
Procedure 37: Bedpan/Fracture Pan:
1. Do initial steps.
2. Lower head of bed.
3. Put on gloves (according to procedure 2).
4. Turn resident away from you.
5. Place bedpan or fracture pan according to manufacturer's directions.
6. Gently roll resident back onto pan and check for correct placement.
7. Cover resident.
8. Raise head of bed to sitting position.
9. Give resident call light and toilet paper.
10. Leave resident and return when called.
11. Lower head of bed.
12. Press bedpan flat on bed and turn resident.
13. Wipe resident from front to back.
14. Provide perineal care if necessary (according to procedure 14).
15. Check urine and or feces for color, odor, amount, and character and report unusual findings to nurse.
16. Cover bedpan
17. Dispose of urine and/or feces, sanitize pan and return according to current nursing practices.
18. Remove gloves (according to procedure 2).
19. Assist resident to wash hands.
20. Do final steps.
Procedure 38: Urinal:
1. Do initial steps.
2. Raise head of bed to sitting position.
3. Put on gloves (according to procedure 2)
4. Offer urinal to resident or place urinal between his legs and insert penis into opening.
5. Cover resident.
6. Give resident call light and toilet paper.
7. Leave resident and return when called.
8. Remove and cover urinal.
9. Take urinal to bathroom, check urine for color, odor, amount and character and report unusual findings to nurse.
10. Dispose of urine, sanitize and return urinal according to current nursing practices.
11. Remove gloves (according to procedure 2).
12. Assist resident to wash hands.
13. Do finals steps.
Procedure 39: Empty Urinary Drainage Bag:
1. Do initial steps.
2. Put on gloves (according to procedure 2).
3. Place paper towel on floor below bag and place graduate on paper towel.
4. Detach spout and point it into center of graduate without letting the tube touch the sides.
5. Unclamp spout and drain urine.
6. Clamp spout.
7. Replace spout in holder.
8. Check urine for color, odor, amount and character and report any unusual findings to the nurse.
9. Measure and accurately record amount of urine.
10. Dispose of urine, sanitize and return graduate according to current nursing practices.
11. Remove gloves (according to procedure 2).
12. Do final steps.
Procedure 40: Weight:
1. Do initial steps.
2. Balance scale.
3. Depending on scale used, assist resident to stand on platform or sit in chair with feet on footrest or transport wheel chair onto scale and lock brakes.
4. When using a standard scale - Move lower weight to fifty pound marks that causes arm to drop. Move it back to previous mark. Move upper weight to pound mark that balances pointer in middle of square. Add lower and upper marks.
5. Subtract weight of wheelchair from total weight, if applicable.
6. Accurately record resident's weight according to current nursing practices.
7. Do final steps.
8. Report unusual reading to nurse.
Procedure 41: Pulse and Respiration:
1. Do initial steps.
2. Place resident's hand on comfortable surface.
3. Feel for pulse above wrist on thumb side with tips of first three fingers.
4. Count beats for 60 seconds, noting rate, rhythm and force.
5. Continue position as if feeling for pulse.
6. Count each rise and fall of chest as on respiration.
7. Count respiration for 60 seconds noting rate, regularity and sound.
8. Record pulse and respiration rates according to current nursing practices.
9. Do final steps.
10. Report any unusual findings to the nurse.
Procedure 42: Auxiliary Temperature:
1. Do initial steps.
2. Position resident comfortably in bed or chair.
3. Rinse thermometer in cool water and dry with a clean tissue.
4. Remove resident's arm from sleeve of gown and wipe auxiliary area with towel.
5. Hold thermometer at stem level and shake down to below the lowest number.
6. Put on disposable sheath, if applicable.
7. Place bulb end of thermometer in center of armpit and fold resident's arm over chest.
8. Hold in place for 10 minutes.
9. Gently remove thermometer, wipe with tissue from stem to bulb or remove sheath and dispose of tissue or sheath.
10. Hold thermometer at eye level, rotate until line appears. Accurately read and record temperature according to current nursing practices.
11. Shake down, clean and store thermometer according to current nursing practice.
12. Put resident's arm back into sleeve of gown.
13. Do final steps.
14. Report any unusual findings to the nurse.
Procedure 42: Oral Temperature:
1. Do initial steps.
2. Position resident comfortably in bed or chair.
3. Rinse thermometer in cool water and dry with clean tissue, if necessary.
4. Hold thermometer at stem end and shake down to below the lowest number.
5. Put on disposable sheath if necessary.
6. Place bulb end of thermometer under resident's tongue.
7. Ask resident to close lips.
8. Leave in place for 3 minutes or longer based on the needs of the individual resident.
9. Remove thermometer, wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath.
10. Hold thermometer at eye level, rotate until line appears. Accurately read and record temperature according to current nursing practices.
11. Shake down thermometer, clean and store thermometer according to current nursing practices.
12. Do final steps.
13. Report any unusual findings to the nurse.
Procedure 44: Blood Pressure:
1. Do initial steps.
2. Clean earpieces and diaphragm of stethoscope with antiseptic wipe.
3. Uncover resident's arm to shoulder.
4. Rest resident's arm, level with heart, palm upward on comfortable surface.
5. Wrap Sphygmomanometer cuff around upper unaffected arm approximately 1-2 inches above elbow.
6. Put ear pieces of stethoscope in ears.
7. Place diaphragm of stethoscope over brachial artery at elbow.
8. Close valve on bulb. If blood pressure is known inflate cuff to 20mm/hg above the usual reading. If blood pressure is unknown, inflate cuff to 160 mm/hg.
9. Slowly open valve on bulb.
10. Watch gauge and listen for sound of pulse.
11. Note gauge reading at first pulse sound.
12. Note gauge reading when pulse sound disappears.
13. Completely deflate and remove cuff.
14. Accurately record systolic and diastolic readings according to current nursing practice.
15. Do final steps.
16. Report unusual readings to the nurse.
Procedure 45: Choking:
1. Call nurse and stay with resident.
2. Ask if resident can speak or cough.
3. If not, move behind resident and slide arms under resident's armpits.
4. Place your fist with thumb side against abdomen midway between waist and ribcage.
5. Grasp your fist with your other hand.
6. Press your fist into abdomen with quick inward and upward thrusts.
7. Repeat until object is expelled.
8. Do final steps.
9. Assist with documentation according to current nursing practices.
Procedure 46: Fire:
1. Remove residents from are of immediate danger.
2. Activate fire alarm.
3. Close doors and windows to contain fire.
4. Extinguish small fire with fire extinguisher if possible.
5. Follow all facility policies.
49. Procedure 47: Seizures: 1. Call for nurse and stay with resident.
2. Place padding under head and remove furniture away from resident.
3. Do not restrain resident or place anything in mouth.
4. Loosen resident's clothing especially around neck.
5. after seizure stops, position resident onto side.
6. Note duration of seizure and areas involved.
7. Do final steps.
8. Assist with documentation according to current nursing practices.
Procedure 48: Falling or Fainting:
1. Call for nurse and stay with resident.
2. Check if resident is breathing.
3. Do not move resident.
4. Talk to resident in calm and supportive manner.
5. Apply direct pressure to any bleeding area.
6. Take pulse and respiration.
7. Assist nurse as directed.
8. Do final steps.
9. Assist with documentation according to current nursing practices.
10. Check resident frequently according to current nursing practices

Created by: shewitt3

"Know" box contains:
Time elapsed:
Retries: