Term
Hand Hygiene (Hand Washing)
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Definition
1 Address client by name and introduces self to client by
name
2 Turns on water at sink
3 Wets hands and wrists thoroughly
4 Applies soap to hands
5 Lathers all surfaces of wrists, hands, and fingers
producing friction, for at least 20 (twenty) seconds,
keeping hands lower than the elbows and the
fingertips down
6 Cleans fingernails by rubbing fingertips against palms
of the opposite hand
7 Rinse all surfaces of wrists, hands, and fingers,
keeping hands lower than the elbows and the
fingertips down
8 Uses clean, dry paper towel/towels to dry all surfaces
of hands, wrists, and fingers then disposes of paper
towel/towels into waste container
9 Uses clean, dry paper towel/towels to turn off faucet
then disposes of paper towel/towels into waste
container or uses knee/foot control to turn off faucet
10 Does not touch inside of sink at any time
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Term
Applies one Knee-High
Elastic Stocking
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Privacy is provided with a curtain, screen, or door
3 Client is in supine position (lying down in bed) while
stocking is applied
4 Turns stocking inside-out, at least to the heel
5 Places foot of stocking over toes, foot, and heel
6 Pulls top of stocking over foot, heel, and leg
7 Moves foot and leg gently and naturally, avoiding force
and over-extension of limb and joints
8 Finishes procedure with no twists or wrinkles and
heel of stocking, if present, is over heel and opening
in toe area (if present) is either over or under toe area
9 Signaling device is within reach and bed is in low
position
10 After completing skill, wash hands
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Term
Assists to Ambulate Using
Tr ansfer Belt
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Before assisting to stand, client is wearing shoes
3 Before assisting to stand, bed is at a safe level
4 Before assisting to stand, checks and/or locks bed
wheels
5 Before assisting to stand, client is assisted to sitting
position with feet flat on the floor
6 Before assisting to stand, applies transfer belt securely
at the waist over clothing/gown
7 Before assisting to stand, provides instructions to enable
client to assist in standing including prearranged signal to
alert client to begin standing
8 Stands facing client positioning self to ensure safety of
candidate and client during transfer. Counts to three
(or says other prearranged signal) to alert client to
begin standing
9 On signal, gradually assists client to stand by grasping
transfer belt on both sides with an upward grasp
(candidate’s hands are in upward position), and
maintaining stability of client’s legs
10 Walks slightly behind and to one side of client for a
distance of ten (10) feet, while holding onto the belt
11 After ambulation, assists client to bed and removes
transfer belt
12 Signaling device is within reach and bed is in low
position
13 After completing skill, wash hands
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Term
Assists With Use of Bedpan
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Definition
1 Explains procedure speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Privacy is provided with a curtain, screen, or door
3 Before placing bedpan, lowers head of bed
4 Puts on clean gloves before handling bedpan
5 Places bedpan correctly under client’s buttocks
6 Removes and disposes of gloves (without
contaminating self ) into waste container and washes
hands
7 After positioning client on bedpan and removing
gloves, raises head of bed
8 Toilet tissue is within reach
9 Hand wipe is within reach and client is instructed to
clean hands with hand wipe when finished
10 Signaling device within reach and client is asked to
signal when finished
11 Puts on clean gloves before removing bedpan
12 Head of bed is lowered before bedpan is removed
13 Avoids overexposure of client
14 Empties and rinses bedpan and pours rinse into toilet
15 After rinsing bedpan, places bedpan in designated
dirty supply area
16 After placing bedpan in designated dirty supply
area, removes and disposes of gloves (without
contaminating self ) into waste container and washes
hands
17 Signaling device is within reach and bed is in low
position
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Term
Cleans Upper or Lower Denture
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Definition
1 Puts on clean gloves before handling denture
2 Bottom of sink is lined and/or sink is partially filled
with water before denture is held over sink
3 Rinses denture in moderate temperature running
water before brushing them
4 Applies toothpaste to toothbrush
5 Brushes surfaces of denture
6 Rinses surfaces of denture under moderate
temperature running water
7 Before placing denture into cup, rinses denture cup
and lid
8 Places denture in denture cup with moderate
temperature water/solution and places lid on cup
9 Rinses toothbrush and places in designated toothbrush
basin/container
10 Maintains clean technique with placement of
toothbrush and denture
11 Sink liner is removed and disposed of appropriately
and/or sink is drained
12 After rinsing equipment and disposing of sink
liner, removes and disposes of gloves (without
contaminating self ) into waste container and washes
hands
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Term
Counts and Records Radial Pulse
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Places fingertips on thumb side of client’s wrist to
locate radial pulse
3 Count beats for one full minute
4 Signaling device is within reach
5 Before recording, washes hands
6 After obtaining pulse by palpating in radial artery
position, records pulse rate within plus or minus 4
beats of evaluator’s reading
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Term
Counts and Records Respirations
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Definition
1 Explains procedure (for testing purposes), speaking clearly,
slowly, and directly, maintaining face-to-face contact
whenever possible
2 Counts respirations for one full minute
3 Signaling device is within reach
4 Washes hands
5 Records respiration rate within plus or minus 2
breaths of evaluator’s reading
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Term
Donning and Removing PPE
(Gown and Gloves)
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Definition
1 Picks up gown and unfolds
2 Facing the back opening of the gown places arms
through each sleeve
3 Fastens the neck opening
4 Secures gown at waist making sure that back of clothing
is covered by gown (as much as possible)
5 Puts on gloves
6 Cuffs of gloves overlap cuffs of gown
7 Before removing gown, with one gloved hand,
grasps the other glove at the palm, remove glove
8 Slips fingers from ungloved hand underneath cuff
of remaining glove at wrist, and removes glove
turning it inside out as it is removed
9 Disposes of gloves into designated waste container
without contaminating self
10 After removing gloves, unfastens gown at neck and
waist
11 After removing gloves, removes gown without touching
outside of gown
12 While removing gown, holds gown away from body
without touching the floor, turns gown inward and keeps
it inside out
13 Disposes of gown in designated container without
contaminating self
14 After completing skill, washes hands
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Term
Dresses Client with Affected (Weak)
Right Arm
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Privacy is provided with a curtain, screen, or door
3 Asks which shirt he/she would like to wear and dresses
him/her in shirt of choice
4 While avoiding overexposure of client, removes gown
from the unaffected side first, then removes gown
from the affected side and disposes of gown into soiled
linen container
5 Assists to put the right (affected/weak) arm through
the right sleeve of the shirt before placing garment
on left (unaffected) arm
6 While putting on shirt, moves body gently and
naturally, avoiding force and over-extension of limbs
and joints
7 Finishes with clothing in place
8 Signaling device is within reach and bed is in low
position
9 After completing skill, washes hands
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Term
Feeds Client Who Cannot Feed Self
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Definition
1 Explains procedure to client, speaking clearly,
slowly, and directly, maintaining face-to-face contact
whenever possible
2 Before feeding, looks at name card on tray and asks
client to state name
3 Before feeding client, client is in an upright sitting
position (75-90 degrees)
4 Places tray where the food can be easily seen by client
5 Candidate cleans client’s hands with hand wipe before
beginning feeding
6 Candidate sits facing client during feeding
7 Tells client what foods are on tray and asks what client
would like to eat first
8 Using spoon, offers client one bite of each type of food
on tray, telling client the content of each spoonful
9 Offers beverage at least once during meal
10 Candidate asks client if they are ready for next bite of
food or sip of beverage
11 At end of meal, candidate cleans client’s mouth and
hands with wipes
12 Removes food tray and places tray in designated dirty
supply area
13 Signaling device is within client’s reach
14 After completing skill, washes hands
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Term
Gives Modified Bed Bath (Face and One
Arm, Hand and Underarm)
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Privacy is provided with a curtain, screen, or door
3 Removes gown and places in soiled linen container,
while avoiding overexposure of the client
4 Before washing, checks water temperature for safety
and comfort and asks client to verify comfort of water
5 Puts on clean gloves before washing client
6 Beginning with eyes, washes eyes with wet washcloth
(no soap), using a different area of the washcloth for
each stroke, washing inner aspect to outer aspect
then proceeds to wash face
7 Dries face with towel
8 Exposes one arm and places towel underneath arm
9 Applies soap to wet washcloth
10 Washes arm, hand, and underarm keeping rest of body
covered
11 Rinses and dries arm, hand, and underarm
12 Moves body gently and naturally, avoiding force and
over-extension of limbs and joints
13 Puts clean gown on client
14 Empties, rinses, and dries basin
15 After rinsing and drying basin, places basin in
designated dirty supply area
16 Disposes of linen into soiled linen container
17 Avoids contact between candidate clothing and used
linens
18 After placing basin in designated dirty supply area, and
disposing of used linen, removes and disposes of gloves
(without contaminating self ) into waste container and
washes hands
19 Signaling device is within reach and bed is in low
position
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Term
Measures and Records Blood Pressure |
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Before using stethoscope, wipes bell/diaphragm and
earpieces of stethoscope with alcohol
3 Client’s arm is positioned with palm up and upper
arm is exposed
4 Feels for brachial artery on inner aspect of arm, at
bend of elbow
5 Places blood pressure cuff snugly on client’s upper arm,
with sensor/arrow over brachial artery site
6 Earpieces of stethoscope are in ears and bell/
diaphragm is over brachial artery site
7 Candidate inflates cuff between 160 mm Hg to
180 mm Hg. If beat heard immediately upon cuff
deflation, completely deflate cuff. Re-inflate cuff to no
more than 200 mm Hg
8 Deflates cuff slowly and notes the first sound (systolic
reading), and last sound (diastolic reading) (If
rounding needed, measurements are rounded UP to
the nearest 2 mm of mercury)
9 Removes cuff
10 Signaling device is within reach
11 Before recording, washes hands
12 After obtaining reading using BP cuff and
stethoscope, records both systolic and diastolic
pressures each within plus or minus 8 mm of
evaluator’s reading
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Term
Measures and Records
Urinary Output
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Definition
1 Puts on clean gloves before handling bedpan
2 Pours the contents of the bedpan into measuring
container without spilling or splashing urine outside
of container
3 Measures the amount of urine at eye level with
container on flat surface
4 After measuring urine, empties contents of measuring
container into toilet
5 Rinses measuring container and pours rinse into toilet
6 Rinses bedpan and pours rinse into toilet
7 After rinsing equipment, and before recording
output, removes and disposes of gloves (without
contaminating self ) into waste container and washes
hands
8 Records contents of container within plus or minus
25 ml/cc of evaluator’s reading
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Term
Measures and Records Weight of
Ambulatory Client
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Client has shoes on before walking to scale
3 Before client steps on scale, candidate sets scale to zero
then obtains client’s weight
4 While client steps onto scale, candidate stands next to
scale and assists client, if needed, onto center of scale
5 While client steps off scale, candidate stands next
to scale and assists client, if needed, off scale before
recording weight
6 Before recording, washes hands
7 Records weight based on indicator on scale. Weight
is within plus or minus 2 lbs of evaluator’s reading
(If weight recorded in kg weight is within plus or
minus 0.9 kg of evaluator’s reading)
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Term
Performs MODIFIED Passive Range of
Motion (PROM ) for One Knee and One
Ankle
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Definition
1 Explains procedure, speaking clearly, slowly, and
directly, maintaining face-to-face contact whenever
possible
2 Privacy is provided with a curtain, screen, or door
3 Instructs client to inform candidate if pain is
experienced during exercise
4 Supports leg at knee and ankle while performing range
of motion for knee
5 Bends the knee and then returns leg to client’s normal
position (extension/flexion) (AT LEAST 3 TIMES
unless pain is verbalized)
6 Supports foot and ankle close to the bed while
performing range of motion for ankle
7 Pushes/pulls foot toward head (dorsiflexion), and
pushes/pulls foot down, toes point down (plantar
flexion) (AT LEAST 3 TIMES unless pain is
verbalized)
8 While supporting the limb, moves joints gently,
slowly, and smoothly through the range of motion,
discontinuing exercise if client verbalizes pain
9 Signaling device is within reach and bed is in low
position
10 After completing skill, washes hands
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