Certified Nursing Assistant Exam: Clinical Skills Performance Checklists

This guide reviews the clinical skills most likely to be required in the clinical performance portion of the certification examination, the Clinical Skills Test (CST). Content for the test includes principles of safe practice, the steps needed to perform each skill, and 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, handwashing, 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 post-procedure 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 compose 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 and 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.

Extra Tip: 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.

Measuring Body Temperature
Handwashing

Extra Tip: 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:
1. Wet hands with warm water and apply soap.
2. Work up lather, cleansing front and back of hands, wrists, between fingers, around cuticles, and under nails.
3. Apply friction for a minimum of 30 seconds (as long as it takes to sing 'Happy Birthday" twice).
4. Keeping fingers lower than wrist, remove all soap.
5. Dry hands with paper towel and limit contact of towel to cleansed hands; turn off water with fresh, dry paper towel and dispose it of.
6. Complete skill without contaminating hands.

Measuring Body Temperature
Obtain temperature reading per method used as documented in the sections that follow for oral, rectal, axillary, and tympanic modes.

Oral Temperature Measurement with Electronic Monitor
1. Remove thermometer pack from charger and attach oral probe to thermometer.
2. Slide disposable plastic probe cover over thermometer probe until the cover stays in place.
3. Ask resident to open mouth; gently place thermometer probe under side of the tongue to the back of the mouth.
4. Ask resident to close mouth around probe with lips closed.
5. Remove probe when you hear an audible beep and see the temperature display on the thermometer.
6. Push ejection button on thermometer to discard plastic probe cover into appropriate receptacle.
7. Clean equipment as needed after use.
8. Return thermometer probe to recording unit.
9. Return thermometer to the charger.
10. Record temp and mode used to obtain the temp according to agency policy.

Rectal Temperature Measurement with Electronic Thermometer
1. Raise side rail and place resident in Sim’s (left side-lying) position.
2. Expose buttocks, keeping rest of body covered.
3. Remove thermometer pack from charger and attach rectal probe to thermometer.
4. Slide disposable plastic probe cover over thermometer probe until the cover stays in place.
5. Dip probe into liberal amount of lubricant applied to a tissue, covering the probe at least 1 to 2 inches.
6. With nondominant hand, separate buttocks to expose anus; ask the resident to breathe slowly and relax.
7. 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.
8. Gently hold thermometer probe in place and remove it when you hear an audible beep and see the temperature display on the thermometer.
9. Push ejection button on thermometer to discard plastic probe cover into appropriate receptacle.
10. Return thermometer probe to recording unit.
11. Wipe the charger and probe with alcohol daily.
12. Return thermometer to the charger.
13. Wipe resident’s anal area with tissue to remove lubricant or feces, and discard the tissue in a biohazard receptacle.
14. Record temp and mode used to obtain the temp according to agency policy.

Axillary Temperature with Electronic Thermometer
1. Remove thermometer pack from charger and attach oral probe to thermometer.
2. Slide disposable plastic probe cover over thermometer probe until the cover stays in place.
3. Raise resident’s arm away from torso.
4. 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.
5. Remove the thermometer probe when you hear an audible beep and see the temperature display on the thermometer.
6. Push ejection button on thermometer to discard plastic probe cover into appropriate receptacle.
7. Clean equipment as needed.
8. Return thermometer probe to recording unit.
9. Record temp and mode used to obtain the temp according to agency policy.

Tympanic Membrane Temperature with Electronic Thermometer
1. Request the resident to position head to one side away from you.
2. Note if there is cerumen (earwax) visible in the ear canal opening; do not attempt to remove cerumen from inside the outer ear canal.
3. Remove handheld thermometer unit from charger.
4. Apply speculum cover over the tip of the unit (speculum), twisting the cover until it is securely in place.
5. 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.
6. Leaving speculum in place, depress the thermometer button to measure the temperature.
7. Leave speculum in place until you hear an audible signal and see the temperature measure on the digital display.
8. Gently remove the speculum.
9. Push ejection button on thermometer to discard plastic speculum cover into appropriate receptacle.
10. Return thermometer to charger.
11. Clean equipment as needed.
12. Record temp and mode used to obtain the temp according to agency policy.

Measuring the Radial and Apical Pulse

Radial Pulse

Checkpoint Critical Step:
1. Place resident in the supine or sitting position.
2. 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.
3. 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.
4. Lightly press against the radial bone until the pulse is absent momentarily, and then release pressure to feel the strongest pulse.
5. Determine the strength of the pulse: pounding-bounding (+4), strong (+3), weak (+2), thready (+1), or absent (0).
6. If the pulse rate is irregular or less than 50 beats per minute (BPM), count the pulse for 60 seconds.
7. Count the pulse for 30 seconds; multiply the total count by 2. If pulse is irregular (less than 50BPM or over 100BPM), notify the nurse.
8. Record results according to agency policy.
9. Record the rate, strength, and rhythm of the radial pulse on the facility form.

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

Apical Pulse
1. Clean earpieces and diaphragm of stethoscope.
2. Assist resident to supine or sitting position. Expose sternum (breastbone) and left side of chest.
3. 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.
4. 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 s econds.
5. Reposition resident’s gown or clothing over chest area and clean ear pieces and diaphragm of stethoscope.
6. Record the rate, strength, and rhythm of the apical pulse on the facility form.

Extra Tip: For testing purposes, count the apical pulse for 60 seconds.

Measuring the Respirations
1. Place resident in supine or sitting position; be sure you can view the chest.
2. Place resident’s arm across the chest comfortably, keeping your hand on the chest or the upper abdomen.
3. 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.
4. If the respirations are irregular, count them for 60 seconds.
5. Record respiratory effort (unlabored to labored), depth (shallow to deep), and rate on the facility form.

Extra Tip: For testing purposes, count respirations for 60 seconds

Blood Pressure
1. Position the resident in supine or sitting position; if the resident has been active, wait at least five minutes before measuring the blood pressure.
2. If resident is sitting, make sure both feet are flat on the floor; no crossed legs.
3. Ask the resident to avoid talking because talking can increase blood pressure by 10–15 mmHg.
4. 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).
5. Locate brachial artery (in bend of elbow on the side closest to the resident).
6. Place the cuff snugly around the upper arm approximately two-finger widths above the elbow.
7. Position the resident’s arm at the level of the heart if sitting or at the resident’s side while lying.
8. If a dial is connected to the cuff, place the cuff so the dial is easily seen.
9. Place the bell of the stethoscope diaphragm over the brachial artery and hold snugly with the fingers of your nondominant hand; avoid touching the resident’s clothing or blood pressure cuff with the stethoscope.
10. Close valve of the cuff pump clockwise until tight.
11. Quickly inflate the cuff (around 8 seconds) to within 30 mmHg above estimated systolic pressure.
12. Slowly release pressure valve, deflating the cuff, and allow needle of manometer gauge to fall at the rate of 2 to 3 mmHg/second.
13. Listen for the first clear sound and the point on the gauge at which you heard the first sound.
14. 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.
15. Continue to slowly deflate the cuff, noting the point at which the muffled sound completely disappears.
16. Listen as the needle moves 10 to 20 mmHg beyond the last sound and allow the cuff to completely deflate.

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 or IV is located.
17. Remove cuff and return resident to comfortable position.
18. Record blood pressure according to agency policy.

Partial Bedbath
1. Check to be certain water is at a safe and comfortable temperature.
2. Drape resident so that only the area of the body being bathed is exposed.
3. Use washcloth without soap to cleanse the face.
4. 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.
5. Pat face dry.
6. Protect bedding by repositioning towel under resident while bath procedure is in progress.
7. Using small amount of soap on washcloth, wash neck, hands, arms, and chest.
8. Dry neck, hands, arms, and chest.
9. Assist resident to turn safely to the side; wash, rinse, and dry back.
10. Warm lotion between your hands; apply lotion to the resident’s back.
11. Provide backrub from base of spine up to neck and shoulders using gentle, circular strokes.
12. Replace gown without exposing resident, and secure it.

Note: For testing purposes, perform a partial bedbath.

Perineal Care of the Female Resident
1. Prepare a basin with comfortable, safe water temperature and place at the bedside.
2. 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).
3. Using a different portion of the washcloth for each stroke, wipe each side of the vulva (area around the vaginal opening).
4. Cleanse the perineum (from bottom of vaginal opening to anus) from top to bottom.
5. Using a fresh washcloth for rinsing, completely remove all soap from the genital area.
6. Dry the perineal area from front to back.
7. Replace the water if it becomes cold or soapy.
8. Place the resident on side for cleansing of buttocks and rectal area.
9. Thoroughly rinse and dry buttocks and rectal area.
10. Place dry pad underneath resident when procedure is complete.
11. Clean and store equipment and leave work area tidy.
12. Report your observations, noting any redness, irritation, discharge, or pain in the perineal or buttocks area.

Nail Care (Fingers and Toes)
1. Soak nails in warm water at safe, comfortable temperature for 10–20 minutes before cleaning under the nails.
2. Use orangewood stick or wooden end of a cotton swab to remove debris from under the nails.
3. Dry residents' hands or feet after soaking.
4. Keep nail edges smooth; use emery board to file until smooth.
CNAs do not cut toenails because of the possibility of injury/infection. Notify the nurse if the resident needs toenails to be trimmed.
5. Apply lotion to residents’ hands or feet after nails are manicured; do not apply lotion between toes.
After massaging hands with lotion, or applying lotion to feet, blot excess lotion with a dry towel. Dry between toes with towel to remove any lotion that may have collected there.
6. Clean and store equipment and leave work area tidy.
7. Report any breaks in skin to the nurse.

Mouth (Oral) Care
1. Position resident in Fowler’s position.
2. Protect clothing from accidental spills.
3. Moisten toothbrush with water and apply toothpaste.
4. Brush all surfaces of teeth, sides of the tongue, and gums with gentle motions.
5. 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.
6. Dry lips and area around mouth.
7. Report any bleeding or presence of lesions (sores) of the mouth to the nurse.

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

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

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

Making an Occupied Bed
1. Check care plan for any precautions needed in moving and positioning the resident.
2. Adjust bed height to comfortable working condition.
3. Lower the side rail on the side where you are working.
4. Loosen the top bed linens at the foot of the bed.
5. 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.
6. 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.
7. 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).
8. Loosen bottom sheet and slide sheet from head of the bed, beneath resident, to the foot of the bed on the side nearest you.
9. Replace side rail up on side and move to opposite side of the bed. Repeat step 8.
10. 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.
11. Clean, disinfect, and thoroughly dry the exposed mattress surface, if soiled.
12. Apply clean linen to the exposed side of the bed, mattress pad 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.
13. 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.
14. Raise the side rail on your side of the bed and move to the opposite side.
15. 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.
16. Clean, disinfect, and thoroughly dry the exposed mattress surface, if soiled.
17. Gently pull clean linens smoothly over edge of mattress from head to foot of the bed, beginning with bottom sheet, and then pull sheet.
18. Tuck edges of pull ends of fitted bottom sheet to fit under the mattress.
19. 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.
20. Assist resident in returning to supine position.
21. 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.
22. Tuck bottom edge of top sheet under the mattress; miter the corners.
23. 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.
24. Turn back top sheet to make cuff over top of the blanket or spread; smooth blanket or spread.
25. Raise the side rails per facility policy.
26. 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.
27. Place call light within easy reach.
28. Lower the bed position to its lowest level.
29. Remove all soiled linen from the room to designated collection area.
30. Report any reddened areas noted on skin while changing linens.
For all the following positions, move the resident in alignment for safe turning.

Moving the Resident to the Side of the Bed
1. Adjust the bed to a comfortable working height, as flat as possible, and lock the wheels.
2. Raise the side rail on the opposite side prior to lowering the side rail closest to you.
3. Stand with your feet apart (one foot in front of the other), back straight, and knees bent.
4. Cross the resident’s arms across the chest.
5. 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.
6. Place your arms under the resident’s waist and thighs; move the middle portion (torso) of the resident’s body toward you.
7. Place your arms under the resident’s legs and move the lower portion of the body toward you.
8. If leaving the resident in the changed position, support head and back with pillow.
9. Check the resident for comfort.
10. Lower the bed and raise the side rails, if ordered.
11. Place the call light within easy reach.

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

Fowler’s Position


1. Raise head of bed at least 30 degrees (low Fowler’s position) up to 90 degrees (high Fowler’s position).
2. 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.
3. Support arms as needed for comfort.

Lateral (Side-Lying) Position


1. Raise the opposite side rail and lock the wheels.
2. Move the resident to the side of the bed nearest you.
3. Flex the resident’s distant arm from you next to the head and place the resident’s arm nearest you across the chest.
4. Cross the resident’s leg nearest you over the other leg at the ankle.
5. Place one hand on the resident’s shoulder and the other hand on the nearest hip.
6. Turn the resident away from you onto the side.
7. Use a positioning device; add a pillow folded lengthwise against the resident’s back to provide back support.
8. Use a positioning device; add a pillow under uppermost leg from knee to below foot.
9. Adjust resident’s arm and shoulder to avoid pressure.
10. Provide positioning device; add a pillow to support shoulder and arm.
11. Lower the bed and the side rail as ordered.

Sim’s Position


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

Prone Position


1. Position the resident on abdomen with face turned to one side; position arms straight or flexed upward toward the head.
2. Keep the bed as flat as possible.

Orthopneic Position



1. Assist the resident to sit straight up or assume a sitting position on the side of the bed.
2. Place a pillow on the overbed table and move the table directly under the upper body of the resident.
3. Assist the resident to lean forward and place both arms, slightly bent, at the elbows, on the pillow for comfort.

Logrolling the Resident


1. Using correct body mechanics, raise the side rails; raise the bed to a comfortable working position and lock the wheels.
2. Keeping the bed as flat as possible, lower the side rail on your working side.
3. Roll the pull sheet placed under the resident up close to the resident’s body.
4. Place a pillow between the resident’s knees.
5. 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.
6. 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.
7. Lower the side rail closest to you.
8. 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.
9. Place the resident in side-lying or Sim’s position.
10. Place pillow behind head and neck for resident comfort.
11. Lower the bed and raise the side rails, if ordered.
12. Place the call light within easy reach.

Assisting the Resident to Sit on the Side of the Bed
1. Position the bed so that the resident’s feet can either touch the floor or a footstool.
2. Raise the side rail behind the resident.
3. Assist the resident to a sitting position.
4. Place one arm behind the resident’s neck and shoulders; place the other arm under the resident’s knees. Raise the head of the bed to a 90 degree angle.
5. Turn the resident toward you so his or her legs hang over the side of the bed.
6. Support the resident while he or she regains balance.
7. Ask resident if he/she is experiencing dizziness or nausea. Encourage the resident to keep his/her head erect with the eyes open. Note that if the resident wears glasses for distance vision, make sure the resident has them on throughout the procedure.
8. Stay with resident to support an upright position, keeping body in straight alignment.
9. Check pulse and respirations.
10. Allow the resident to remain in the dangling position for 15–20 minutes or as ordered.
11. Return the resident to bed by reversing the process.

Assisting the Resident to Transfer from the Bed to a Chair or Wheelchair
1. Place the chair next to the bed on the resident’s strong side.
2. If using a wheelchair, lock the wheels and fold the footrests to the outside of the chair.
3. Place the bed in the lowest position and lock the wheels.
4. If side rails are up, lower the one nearest you.
5. Assist the resident to put on nonskid shoes and a robe.
6. 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.
7. Place nonskid footwear on resident’s feet before standing to prevent sliding of resident’s feet on floor.
8. 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.
9. 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.
10. 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.
11. 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.

Transferring the Resident from a Bed with a Mechanical Lift
Below is an example of a mechanical lift that you might use to transfer the resident, as documented in the list that follows.


1. Ask for assistance to operate the lift.
2. Gather the lift and all supplies at the bedside.
3. Wheel the lift into position with the foot extensions under the bed on the side where the chair is positioned.
4. Set the adjustable base at its widest setting to assure its stability. Lock the wheels of the lift.
5. Secure the lifting chains to handles on the side of the lift sling.
6. 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.
7. 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.
8. Attach the lift straps or hooks to the openings on the lift seat and gradually lift the resident above the bed surface.
9. 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.
10. Move the client over the chair making certain that the hydraulic valve is closed.
11. Releasing the hydraulic valve very slowly and smoothly, lower the client into the chair.
12. Secure the resident throughout the lift for protection and reassurance.
13. Following the lift into the chair, wheelchair, or stretcher, leave the sling under the resident for easy return to bed as ordered.
14. Apply seat belt or other restraint as needed.
15. Place the call light within easy reach.
16. 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.
17. Clean and store the lift per facility policy.

Moving the Resident from a Bed to a Stretcher (Gurney)
1. Ask for assistance from two or three coworkers.
2. Raise the bed to a comfortable working height and lock the wheels.
3. Remove the top linen and cover with a bath blanket; loosen the pull sheet.
4. If the side rail is up, lower it on your side.
5. Grasp the pull sheet at the resident’s shoulder’s and 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 to the side of the bed.
6. Position the stretcher against the side of the bed closest to you at the same height as the bed and lock the wheels.
7. 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.
8. 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.
9. 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.
10. Unlock the wheels on the stretcher and transport the resident feet first with the help of another coworker.
11. Remain with the resident until relieved by another staff member.

Using a Gait-Transfer Belt to Assist the Resident to Ambulate


1. 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 in Figure 6.8.
2. Stand directly in front of the resident with legs slightly apart.
3. 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.
4. Transfer one of your hands to the side of the gait-transfer belt; move the other hand to hold the belt in the back.
5. Check to be sure the resident has on non-skid footwear, is covered with a robe or clothing, and is wearing distance vision glasses if applicable.
6. To ambulate the resident, keep hands in current position and walk at the resident’s side and slightly behind his or her knees.
7. Check frequently to see if resident is feeling unsteady, experiencing dizziness, nausea, or pain.
8. 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.

Passive Range of Motion Exercises
1. Raise the bed to a comfortable working height and lock the wheels.
2. Position the resident in the supine position with pillow under head.
3. Exercise each shoulder, rotating the shoulder joint smoothly; abduct and adduct the shoulder.
4. Supporting the wrist and elbow, exercise the elbow and forearm by flexing and extending the lower arm.
5. Rotate and flex the wrists, one wrist at a time, from side to side (ulnar deviation and radial deviation).
6. Flex and extend each hand at the wrist.
7. Flex and extend the fingers and thumb of each hand.
8. Exercising each leg at a time, support the foot from behind the ankles, and flex the lower legs by bending the knee.
9. Throughout movements, ask resident about pain. If the resident experiences pain at any point in the procedures, stop at that point and report the resident’s pain and its location to the nurse.
10. Exercising each leg at a time, support each foot from behind the ankles, and adduct and abduct the legs at the hip.
11. Exercising each hip at a time, rotate each leg at the hip, supporting the ankle.
12. Supporting each foot behind the instep, rotate, flex, and extend the foot at the ankle.
13. Grasp, flex, and extend the toes.

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.

Caution
Monitoring Resident in Restraints
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.
Provide comfort for resident while in restraints.

Feeding
1. Follow agency policy for proper identification of the resident to ensure that the meal is the correct one prepared for the resident.
2. Position resident in sitting position.
3. Offer and assist resident to toilet and/or wash hands before feeding.
4. Sit at eye level with resident for feeding.
5. Protect clothing from spills.
6. Provide fluids (at least every 3 to 4 bites of food) to drink during feeding. Encourage the resident to choose which food to eat next throughout the feeding.
7. Use a spoon to feed resident.
8. Make sure resident has swallowed before offering additional bites of food.
9. Encourage resident to complete meal to receive maximum benefit of diet.
10. Talk with resident during feeding to encourage interaction and increase satisfaction with feeding experience.
11. Leave area around resident’s mouth clean and dry.
12. Record food intake in percentages.
13. Document I & O for fluids as ordered for the resident.
14. Report any resident problems with feeding procedure.

Performing Ostomy Care
Offering the Bedpan
1. To protect bed linens, place a protective pad directly under resident's buttocks.
2. Using the correct size bedpan to fit the resident (a fracture pan might be necessary for immobilized resident), ask the resident to roll to opposite or position resident on side opposite you and place the bedpan under resident to allow for comfort and collection of urine or stool.
3. After the bedpan is in place, raise the head of bed to resident’s comfort level.
4. Provide resident with toilet tissue before removing the bedpan.
5. Before removing the bedpan, lower the head of the bed. Anchor the bedpan firmly as the resident rolls away from it.
6. Empty bedpan contents into toilet.
7. Cleanse and dry the perineal area as necessary to remove urine or stool.
8. Rinse, dry, and store bedpan in bottom drawer of bedside cabinet.
9. Record output (record total urine output in cc or mL, according to facility procedure; if recording stool, estimate the amount expelled).
10. Report unusual amount, color, odor, and consistency of stool or resident discomfort.

Performing Ostomy Care
1. Carefully remove ostomy appliance that is attached to the skin.
2. Gently but firmly cleanse the skin around the stoma with soap and water, and dry the area thoroughly.
3. Apply skin protector around the stoma as ordered.
4. Empty the collection bag and note the amount, color, and consistency of the stool.
5. Wash thoroughly with soap and water.
6. Reattach the appliance per manufacturer’s instructions and fasten the clamp to prevent leakage.
7. Record the procedure and report any redness, irritation, open lesions, or resident discomfort to the nurse.

Administering a Cleansing Enema
1. Assemble equipment and supplies at the bedside; prepare the cleansing enema solution:
Keep water temperature at 105°F; add manufacturer’s soap to water (do not use bar soap); flush enema tubing with water to expel air from tubing; clamp tubing securely.
2. Raise the side rails and raise the bed to a comfortable working position.
3. Assist the resident onto the left side in the Sim’s position and cover with a bath blanket.
4. Position an I.V. pole beside the bed and raise the side rail.
5. Hang the enema bag on I.V. pole with the tubing at the bottom of the bag. Hang no higher than 18 inches above the bed or 12 inches above the resident’s anus.
6. Apply gloves.
7. Lower the side rail and place a protective pad under the resident’s buttocks.
8. Lubricate four inches of the tip of the enema tubing.
9. Ask the resident to breathe deeply to help relieve cramping during the procedure.
10. With one hand, lift the upper buttock to expose the anus; with other hand, carefully insert the tubing tip into the rectum, rotating it approximately 2–4 inches into the rectum. If you feel resistance or the resident complains of pain, stop the procedure and notify the nurse.
11. Unclamp the tubing and allow the solution to flow slowly into the rectum. If the resident complains of cramping, clamp the tubing and stop the flow; resume in a minute or so to instill as much liquid as possible.
12. Ask the resident to hold the solution inside the rectum as long as possible.
13. Lower the bed position and assist the resident to the bathroom or the bedside commode; if unable to leave the bed, place the resident on a bedpan to expel the enema fluid and stool; place the call light within easy reach.
14. Discard the equipment and supplies in the garbage receptacle and clean area.
15. Return to the bedside or bathroom when the resident has completed the toileting process.
16. Provide perineal care.
17. Observe the expelled stool; flush toilet or empty commode or bedpan.
18. Apply clean gloves; wash and disinfect commode or bedpan and return for storage; remove gloves and wash hands.
19. Lower the bed and raise the side rails per facility policy.
20. Record the amount, color, and consistency of the expelled stool.

Measuring and Recording Output from a Urinary Drainage Bag
Recording Intake and Output (I & O)
1. Identify foods considered to be liquid and estimate intake by the resident.
2. Record amount of liquid taken by the resident in cubic centimeters (cc) or milliliters (mL), according to facility policy.
3. Measure output by pouring the contents of the urine receptacle (urinal or bedpan) into a graduate. Place graduate on a clean barrier and on a flat surface to read the amount of urine at eye level.
4. Flush the urine down the toilet.
5. Rinse and disinfect the graduate and bedpan or urinal according to facility policy.
Remove gloves.
6. Using a pen, record the amount of urine in the Output column of the I & O form.
7. Report any unusual color, amount, odor, or particles noted in the urine to the nurse.

Measuring and Recording Output from a Urinary Drainage Bag
1. With gloved hands, open drain (at bottom of urinary drainage bag) and drain the urine into the graduate, which is placed on a barrier of two paper towels on the floor. Empty urine bag into graduate without touching drain to the graduate.
2. Wipe drain with alcohol swab after emptying urine and return drain to the cover on the urinary drainage bag, being careful not to touch the drain to the bag while inserting it into the cover.
3. Secure urinary drainage bag to the bed frame; never hang the bag on the side rail or other movable part of the bed.
4. Place graduate at eye level on a flat surface covered with a paper towel to read the level of urine collected.
5. Empty urine into toilet; rinse and store the graduate; discard the paper towel.
6. Remove gloves and wash hands.
7. Record output.
8. Report any unusual odor, color, consistency, or particles noted in the urine to your supervisor.

Indwelling Catheter Care
1. Raise the resident’s bed to a comfortable working height. Provide for privacy by screening the resident from view.
2. Position the resident: For a female, position dorsal recumbent (on back) with head slightly elevated and knees bent; for a male, use the supine or Fowler’s position.
3. Place waterproof pad under resident’s buttocks.
4. Cover resident to expose only the perineal area.
5. For a female, use your non-dominant hand to gently pull open labia to fully expose urethral meatus and catheter insertion site, keeping hand in this position throughout procedure. For a male, use your nondominant hand to retract the foreskin if not circumcised, and hold penis firmly at shaft just below the glans (end of penis), keeping hand in this position throughout the procedure.
6. Observe urethral meatus and tissue for color, odor, swelling, and consistency of discharge.
7. Cleanse perineal tissue: keep water in bath basin at temperature that is 110 to 115 degrees. Check periodically throughout the procedure to assure water temp is comfortable for the resident.
8. For a female, one clean, soapy cloth and cleanse urethral meatus toward anus and catheter, from top of meatus toward anus. Use only one cloth per wipe. Do not return dirty cloth to clean water. For a male, while spreading urethral meatus, cleanse around catheter first, then wipe in circular motion around meatus and glans to base of the penis.
Rinse area with warm, clean water, one cloth per wipe. Dry well.
9. While holding the catheter with your nondominant hand, cleanse down the catheter 3 to 4 inches. Rinse and blot area and catheter dry with clean towel.
10. For uncircumcised male residents, replace the foreskin over the glans.
11. Remove the pad from under the buttocks and leave the resident on a dry pad.
12. Check tubing. Observe tubing for proper drainage, keeping tubing free of kinks or obstructions. Assure that the resident is not lying on drainage tubing.
13. Keep drainage bag lower than the bladder; assure that the bag is attached to the bed frame, not the bed side rail and not on the floor.
14. Position resident for comfort.
15. Unscreen the resident.
16. Dispose of equipment, making sure the bath basin is washed and dried before storing.
17. Report and record characteristics of drainage, appearance of perineal area, or any discomfort reported by the resident.

Applying a Condom Catheter
1. Provide perineal care.
2. Remove the protective backing from the catheter’s adhesive surface.
3. Roll the catheter onto the penis, moving from the end of the penis (glans) toward the body.
4. Leave one inch of space between the penis and the end of the catheter.
5. Apply tape in spiral direction to secure the catheter. Never completely encircle the penis (to avoid a tourniquet effect).
6. Connect the catheter to the drainage bag.
7. Tape the catheter to the resident’s inside thigh to prevent traction on the catheter.
8. Fasten the drainage bag to the bed frame. Never fasten the drainage bag to a movable part of the bed.
9. Record the procedure and the resident’s response.
10. Remove the catheter for perineal care at least once daily; report any redness, swelling, or discomfort to the nurse.
11. Add the specimen amount to the output total.

Collecting Specimens
Prepare specimen label and follow the procedures for the different specimens documented in the sections that follow.

Safety Tip
All specimens should be placed in a laboratory biohazard bag, sealed and stored, or transported to the laboratory according to agency policy.

Routine Urine Specimen
1. Assisting if necessary, ask the resident to urinate into a clean bedpan, urinal, or specimen collection pan (hat).
2. Carefully remove the specimen container lid and lay the lid on a solid surface with the inside up.
3. Pour at least 5ccs (mLs) of urine from the bedpan, urinal, or hat into the specimen container.
4. Carefully replace the lid on the container to avoid touching the inside of the lid or the container.
5. Clean and store the bedpan or urinal in the bottom drawer of the bedside table; never place the urinal or the bedpan on the overbed table.
6. Attach the label to the container and take the container to the designated location.

Clean Catch Urine Specimen
1. Provide perineal care.
2. Position the resident on a bedpan, provide a urinal, or assist to the bathroom.
3. Carefully remove the specimen container lid and lay the container lid on a solid surface with the inside up.
4. Instruct the resident to begin voiding and then stop.
5. Holding the specimen container under the resident, instruct him or her to resume voiding and collect at least 5ccs of urine.
6. Instruct the resident to finish voiding.
7. Carefully replace the lid on the container to avoid touching the inside of the lid or the container.
8. Clean and store the bedpan or urinal in the bottom drawer of the bedside table; never place the urinal, bedpan, or hat on the overbed table.
9. Attach the label to the container and take the container to the designated location.

Urine Specimen from an Indwelling Catheter
CNAs do not collect urine specimens from an indwelling catheter because this is a sterile procedure reserved for the nurse.

Isolation Procedures

Stool Specimen
1. Assist the resident to void if necessary.
2. Carefully remove the specimen container lid and lay the container on a solid surface with the inside up.
3. Place the resident on a bedpan or place a specimen pan (hat) under the toilet seat.
4. Instruct the resident not to dispose of toilet tissues into the bedpan or hat; provide a disposable bag for soiled tissues.
5. Place the call light within easy reach.
6. When the resident is finished, remove the resident from the bedpan or assist from the bathroom.
7. Provide perineal care.
8. With gloved hands, use a tongue depressor to transfer one to two tablespoons of stool from the bedpan to the specimen container.
9. Wrap the tongue depressor in paper towel and discard it in the disposable bag.
10. Remove gloves; carefully replace the lid on the container to avoid touching the inside of the lid or the container.
11. Clean and store the bedpan in the bottom drawer of the bedside table; never place the bedpan on the overbed table.
12. Place the disposable bag of tissues in a biohazard waste container.
13. Attach the label to the container and take the container to the designated location.
14. Add the stool elimination to the daily stool count.

Isolation procedures follow CDC guidelines for various medical conditions that require protection among residents to control the spread of disease. The following guidelines apply to individual supplies and equipment that might be required for a particular type of isolation.

Choking Relief
When discovering a resident who is choking and loses consciousness:
1. Ease the resident to the floor; attempt respirations.
2. If breath will not enter, reposition the resident to help expose the airway; attempt respirations again.
3. If still unsuccessful, use firm back slaps, chest thrusts, abdominal thrusts until the object is dislodged and can be removed.
4. After removing the object, check for pulse and respirations. If neither is present, start chest compressions and/or rescue breathing until the resident resumes breathing or until relieved by another rescuer.

Putting on Disposable Gown, Gloves, Goggles, and Mask
1. Remove watch and place on a paper towel for transport into resident room (keep on towel until needed for vital signs).
2. Wash hands and dry thoroughly.
3. Put on disposable gown with opening at the back; tie the neck ties.
4. Tie the gown’s waist ties, ensuring that the back edges of the gown cover your uniform.
5. Don a mask, adjusting it to cover your nose and mouth; tie the mask securely at the back of your head or slip elastic bands on the side of the mask over your ears.
6. Don goggles over eyes and adjust to fit well.
7. Don gloves, ensuring that the gown cuffs are covered by the cuff edges of the gloves.

Removing Disposable Gown, Gloves, Goggles, and Mask
1. Remove gloves, turning them inside out and placing them in the biohazardous waste receptacle.
2. Wash hands.
3. Holding them only by the elastic bands, remove goggles or face shield.
4. Without touching the outside of the gown, ease one hand inside the cuff of the gown on the opposite arm and pull the gown down over the other arm.
5. Using the same technique, pull the gown down from the other arm.
6. Fold and roll the gown away from you, with outside (contaminated side) folded to the inside.
7. Discard the gown in the biohazardous waste receptacle.
8. Remove the mask by grasping only the ties or elastic bands at the mask sides.
9. Untie the bottom tie first, and then the top tie or slip the elastic bands over your ears.
10. Dispose of the mask in a covered trash receptacle.
11. Wash and dry your hands.
12. Place your watch in your pocket; dispose of the paper towel in the trash receptacle.
13. Use a paper towel to open the door of the resident’s room.
14. Discard the towel inside the room.
15. Repeat handwashing per facility policy.

Assisting with Post-Mortem Care
1. Wash hands.
2. Collect the following:
- Post-mortem kit, containing shroud/body bag
- Bed linen protector
- Towels and washcloths
- Bath basin
- Denture cup
- Tape
- Cotton balls
- Valuables envelope
3. Don gloves.
4. Raise bed and adjust to flat position to promote good body mechanics.
5. Place body in supine position.
6. Gently place the eyelids over the eyes. Apply moistened cotton balls over each eye if needed to keep eyes closed.
7. Follow agency policy regarding denture care. In most cases, leave in place and notify the nurse so he/she can record that dentures are in the resident’s mouth.
8. Close the resident’s mouth (you may place a rolled washcloth beneath the chin to maintain alignment).
9. Follow agency policy for jewelry removal. Record all jewelry removed.
10. Unless an autopsy is ordered, assist the nurse to remove all drainage bags, tubes, and catheters.

Note
To avoid contamination, follow aseptic technique in dispose of soiled dressings, linens, and other resident care items.
11. Wash body with plain water and dry thoroughly.
12. Replace soiled dressings with clean ones.
13. Dress body in a clean gown.
14. Comb hair and rearrange as needed.
15. Use tags and identify the body (apply to ankle and opposite big toe).
16. Place body in shroud and label outside of the shroud.
17. Cover the body with a clean sheet up to shoulder level.
18. Label all gathered resident belongings. Leave the labeled denture cup with the body.
19. Tidy up the room.
20. Remove gloves and wash hands.
21. Pull the privacy curtain and close the resident’s room door.
22. Per agency procedure, discard used supplies and return equipment to area for cleaning.
23. Following agency procedure, report disposition (what was done) with resident’s valuables.