Skills Tasks

Card Set Information

Skills Tasks
2011-03-21 21:26:09

State Skills
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  1. Blood Pressure
    • 1. Clean ear pieces and diaphragm with antiseptic wipe.
    • 2. Position residents arm resting on firm surface with palm up.
    • 3. Wrap cuff around arm with bladder over artery 1" above antecubital space-cuff even and snug.
    • 4. Place ear pieces in ears and diaphragm over artery.
    • 5. inflate cuff no more than 180mm/Hg or may use pulse obliteration method, candidate choice.
    • 6. Deflate cuff, note systolic reading, note point of diastolic reading.
    • 7. Accurate reading within 4 mm/Hg windown on both systolic & diastolic
    • 8. Accurately record blood pressure.
  2. Tympanic Temperature
    • 1. Place tympanic thermometer cover on.
    • 2. Ask person to turn his head so ear is in front of you, new probe cover on.
    • 3. Pull back on the ear (gentle, firm) to straighten the ear canal and insert probe gently.
    • 4. Start the thermometer.
    • 5. Wait until you hear a beep or flashing light and remove.
    • 6. Read the temperature and record accurately.
  3. Electronic or Digital Temperature
    • 1. Oral: Ask the person if they have eaten or consumed a beverage, cold or hot, ot smoked within the last 15 minutes.
    • 2. Place a sheath on the probe.
    • 3. correct placement for obtaining oral reading or auxillary reading.
    • 4. If necessary, hold the probe in place for oral.
    • 5. Leave the probe in place until the instrument beeps.
    • 6. Remove the probe sheath from the probe and dispose of properly.
    • 7. Replace the probe.
    • 8. Document accurately.
  4. Glass or Disposable Temperature
    • 1. Clean thermometer prior to use.
    • 2. Oral: Ask the person if they have eaten or consumed a beverage, cold or hot, or smoked with in the last 15 minutes.
    • 3. Shake thermometer to below 95 degrees.
    • 4. Place a sheath on the probe.
    • 5. Follow all above procedures of all thermometers.
    • 6. Hold or leave the thermometer in place for 3 to 5 minutes.
    • 7. Document accurately.
  5. Radial or Apical Pulse
    • 1. Locate pulse at the correct site.
    • 2. count pulse for 30 seconds and double the count for 1 full minute. Accuracy within + or - 4 beats per minute.
    • 3. Document accurately
  6. Respiratory Rate
    • 1. Count respirations for 30 seconds and double or count for 1 full minute. Accuracy within + or - 2 breaths.
    • 2. Document accurately.
  7. Handwashing
    • 1. Don't touch the sink with your uniform.
    • 2. Turn water to warm.
    • 3. Wet and soap hands.
    • 4. Wash hands with fingers down for 15-30 seconds, including wrist, nails, and between fingers.
    • 5. Rinse with fingertips down.
    • 6. Use dry paper towel to dry hands.
    • 7. Use same paper towel to turn off faucets.
    • 8. Discard paper towels appropriately.
  8. Pressure Ulcer Prevention
    • 1. Demonstrate 2 ways to prevent pressure ulcers: proper use of bed cradle, elbow/heel protector, or using pillows to reduce skin to skin contact.
    • 2. Explain 2 other ways to prevent pressure ulcers: changing position frequently, good nutrition and hydration, and encourage mobility.
  9. Position Foley Catheter/Bag/Tubing
    • 1. Secure tubing to residents inner thigh or abdomen.
    • 2. Place tubing over leg.
    • 3. Position tubing to facilitate gravitational flow, no kinks.
    • 4. Attach to bed frame (not over or on side rail) always below level of bladder.
    • 5. Keep catheter bag from touching the floor.
  10. Oxygen
    • 1. Demonstrate correct placement of O2 mask or nasal cannula (place prongs following the contour of the nasal passage).
    • 2. Demonstrate how to check the oxygen flow meter and verbalize actions needed if flow rate is not accurate.
    • 3. Verbalize 3 oxygen use guidelines: No kinks in the tubing, provide frequent oral care, avoid lighting matches or smoking around oxygen use, and ensure that all electrical equipment is in good repair.
  11. Occupied Draw Sheet Change
    • 1. Place clean draw sheet on clean surface within reach (chair or over-the-bed table).
    • 2. Provide privacy throughout procedure.
    • 3. Lower head of bed, placing patient in supine position.
    • 4. After raising side rail, assist resident to turn onto side, moving toward raised side rail.
    • 5. Loosen draw sheet, roll soiled draw sheet toward patient.
    • 6. Place and tuck in clean draw sheet on working side.
    • 7. Raise side rail and assist resident to turn onto clean draw sheet.
    • 8. Remove soiled linens/draw sheet, avoiding contact with clothes, and place in appropriate location within room - never on the floor.
    • 9. Pull and tuck in clean draw sheet, finishing with sheet free of wrinkle.
  12. Apply Cold Pack or Warm Compress
    • 1. Cover cold/warm compress with towel or other protective cover (pack or compress should not be placed on bare skin without covering)
    • 2. Properly place on correct site as directed by skills examiner
    • 3. When asked by examiner, verbalizer frequency of checks and how long you would leave pack/compress on resident (initially check after 5 minutes/do not leave on patient for more than 20 minutes)
  13. Measure and Record Fluid Intake
    • 1. Calculate intake in mL's.
    • 2. Measure on a flat, level surface.
    • 3. Record intake accureately within +/- 25 mL's of nurses reading.
  14. Converting Ounces to mL's (30 mL's = 1 oz)
    • 1. Convert ounces to mL's.
    • 2. Record intake accureately within +/- 25 mL's of the nurses reading.
  15. Empty Down Drainage Bage and Measure/Record Urine Output
    • 1. Collect paper towel/measureing container.
    • 2. Place paper towel on floor and place measuring container on paper towel.
    • 3. Remove drainage tube from storage sheath.
    • 4. Unclamp while directed toward container and facilitate gravity flow.
    • 5. Empty contents- (tube should not touch side of graduate).
    • 6. Clean tip of drainage with alcohol swab.
    • 7. Re-clamp and reinsert tube into storage sheath.
    • 8. Place on flat surface, measure accurately in mL's.
    • 9. Dispose of properly into toilet.
    • 10. Rinse and dry container.
    • 11. Remove gloves, wash hands.
    • 12. Record intake accurately within +/- mL's of nurses reading.
  16. Isolation Precautions
    • Step 1: Putting on gown.
    • 1. Put on gown by slipping arms into the sleeves.
    • 2. Secure the gown around your neck.
    • 3. Overlap edges of gown so your uniform is completely covered.

    • Step 2: Putting on Mask:
    • 1. Place mask over nose and mouth.
    • 2. Tie the upper strings or ear loops over your ears.
    • 3. Tie the lower strings at the back of your neck.
    • 4. Make sure that the mask fits snugly around your face.

    • Step 3: Putting on Gloves:
    • 1. Put on glvoes - the cuffs of the glvoes should extend over the cuffs of the gown.

    • Step 4: Remove Gloves
    • 1. Make sure glove touches only glove.
    • 2. Grasp a glove just below the cuff.
    • 3. Hold the removed glove with the other gloved hand.
    • 4. Reach inside the other glove with the first two fingers of your ungloved hand.
    • 5. Pull the glove down (inside out) over your hand and the other glove.
    • 6. Discard the gloves in the trash.

    • Step 5: Removing Gown
    • 1. Untie the ties of gown.
    • 2. Untie the neck tie and loosen the gown at the neck.
    • 3. Pull the gown inside out as it is removed.
    • 4. Roll up the gown away from you.
    • 5. Discard of gown in residents room.

    • Step 6: Removing Mask
    • 1. Untie bottom strings first and then untie top strings.
    • 2. Remove mask by holding the ties only.
    • 3. Dispose of the mask in the container located in residents room.
  17. Postmortem Care
    • 1. Position the body supine in proper body alignment.
    • 2. Bathe soiled areas and dry thoroughly.
    • 3. Place a clean gown on the body.
    • 4. Gently pull eyelids over eyes.
    • 5. Insert dentures if needed.
    • 6. Close mouth - place a rolled towel under the chin to support the mouth if necessary.
    • 7. Remove any jewelry.
    • 8. List all jewelry removed and secure according to facility policy.
    • 9. Brush and comb hair as necessary.
    • 10. Cover the body to the shoulders wiwth a sheet if the family will view the body.
    • 11. Make sure room is neat.
    • 12. Allow family to view the body, provide privacy.
    • 13. Give the person's belongings to the family.
  18. Abdominal Thrust (Conscious Patient Only)
    • 1. Candidate is able to identify symptoms of choking, asks resident "Are you choking?"
    • 2. Call for help
    • 3. Stands behind resident and wraps arms around resident's waist.
    • 4. Places the thumb side of the fist against the resident's abdomen.
    • 5. Positions fist slightly above navel and below the xyphoid process.
    • 6. Grans first with other hand, press fist and hand into the resident's abdoment with an inward, upward thrust.
    • Candidate should indicate that they would repeat this procedure until it is successful or until the victim loses consciousness.
  19. Obtain and Record Weight and Height
    (Standing Scale Only)
    • 1. Move weights to zero before assisting resident on to scale.
    • 2. Assist resident to stand on scale.
    • 3. Ensure resident is balanced and centered on the scale with arms at side.
    • 4. Accureately record weight within +/- 2 lbs. of nurse's measurement.
  20. Height
    • 1. Assist patient to stand on scales with height measurement facing away from the measuring bar.
    • 2. Resident is balanced and centered on the scale with arms at side.
    • 3. Raise folded measuring bar above patient head, open and lower gently until bar rest of top of the head (not hair).
    • 4. Accureately record height within +/- .5 inch of nurses's measurement.
  21. Application of Anti-Embolism Stockings (TED hose)
    • 1. Should apply while resident is in bed or with feet elevated.
    • 2. Hold foot and heel of stocking and gather up stocking - turning stocking inside out down to the heel, aids in application.
    • 3. Smooth up and over leg so hose is even, snut and not twisted or wrinkled.
    • 4. Heel and toe in proper location.
    • 5. If there is a hole at the foot portion of the hose, it makes no difference if it is on top of the foot or the bottom. (The hole was put there by the different manufacturers, to check circulation of the toes)
  22. Passive Range of Motion 2 Joints - Examiners Choice
    • 1. Excercise passively 2 joints.
    • 2. Never exercise past the point of pain or resistance.
    • 3. Provide support for joint.
    • 4. Avoid fast jerky movements, use flexion, extension, abduction or rotation if applicable.
    • 5. Repeat exercise at least 3 times or as ordered.
  23. Moving and Positioning Residents - Examiners Choice
    • 1. Draw Sheet:
    • Move using a draw sheet (2 persons): Provide suppoert for residents head. Grasp rolled draw sheet near residents shoulder's and hips.
    • 2. Fowlers:
    • Position in Fowler's (high Fowlers is 60-90 degrees; semi-Fowler's is 30-45 degrees; all include elevating knees approximately 15 degrees.
    • 3. Supine:
    • Position in supine, proper anatomical alignment.
    • 4. Chair/Wheelchair
    • Position in chair or W/C: provide good alignment-upper body and head erect, back and buttocks against back of chair, feet flat on floor or on W/C footrests.
    • 5. Sims/Enema/Semi Prone:
    • Position in Sims' position-left side lying, right leg flexed, lower arm behind resident. Provide good alignment by placing a pillow under the head, upper arm and upper leg.
    • 6. Lateral:
    • Position in lateral/side-lying on the correct side as directed by examiner, using pillows for proper anatomical alignment.

    • With each of the above positions you must demonstrate:
    • Raise side rail while turning patient except on side you are working on.
    • Demonstrate proper body mechanics.
    • Maintain proper alignment at all time, for all positions.
  24. Assisting to Ambulate
    Demonstrating Proper Use of a Gait Belt
    • 1. Resident should have footwear with non-skid soles.
    • 2. Sit resident up, allow to dangle.
    • 3. Apply gait belt properly around resident's waist; avoid restricting circulation or breathing, or injury to skin.
    • 4. Assist resident to stand while holding gait belt.
    • 5. Maintain own body mechanics while assisting resident to stand.
    • 6. Walk at resident's side or slightly behing (on weak side, if resident has a weak side).
    • 7. Demosntrate proper use of assistive devices (walker, cane-should be place on residents strong side).
  25. Transferring From a Bed to a Wheelchair
    Demonstrating Proper Use of Gait Belt
    • 1. Lock the bed wheels.
    • 2. Resident should have footwear with non-skid soles.
    • 3. Move or remove foot rests from wheelchair.
    • 4. Lock wheelchair brakes.
    • 5. Lower bed and rails.
    • 6. Sit resident up, allow to dangle.
    • 7. Apply gait belt properly around resident's waist; avoid restricting circulation or breathing, or injury to skin.
    • 8. Assist resident to stand while holding gait belt.
    • 9. Maintain own body mechanics while assisting resident to stand.
    • 10. Transfer to the strong side, using proper technique.
    • 11.Position resident properly in wheelchair with residents hips against back of seat.
    • 12. Remove gait belt without harming resident.
    • 13. Place footrests under residents' feet.
  26. Restraints
    • 1. Apply restraint properly to individuals, secure but not tight (1-2 finger width).
    • 2. You must secure restraint to stable foundatin (bed frame if patient is in bed).
    • 3. Demonstrate how to tie a quick-release knot.
    • 4. Assess breathing/circulation
    • 5. When asked by examiner, verablize frequency of checks and how often to release restraint for exercies, toileting or other activity.
    • Check every 2 hours and release for 15 minutes.
  27. Denture Care
    • 1. Before handling dentures, protect dentures from possible damage (line the sink or basin with a towel or washcloth or fill with water).
    • 2. Crush dentures under running water (neither hot nor cold) with toothbrush and toothpaste.
    • 3. Place dentures in denture cup with water, adding cleaning tablet (if available), cover with lid and allow to soak.
    • 4. Perform mouth care while dentures are out of the mouth.
  28. Log Rolling Resident With Hip Fracture Precautions
    • 1. Use at least 2 persons and draw sheet.
    • 2. Lower head of bed as flat as possible.
    • 3. Do not roll resident onto injured side.
    • 4. Place abduction splint or pillows between legs to supprt hip.
    • 5. Maintain proper body alignment throughout movement.
  29. Oral Care for an Unconscious Resident/Aspiration Precautions
    • 1. Verbalize frequency of oral care (every 2 hours).
    • 2. Place towel or drape under the resident's head.
    • 3. Position resident (as resident's medical condition indicates) to prevent aspiration: in the side lying position (lateral) or with the head of the bed elevated with head turned to the side.
    • 4. Insert swab/sponge tip gently into resident's mouth.
    • 5. Do not use toothpaste/toothbrush.
    • 6. Rotate against all tooth surfaces, mucous membranes and tongue.
    • 7. Clean resident's lips.
    • 8. Moisturize lips.
    • 9. Report abnormalities such as bleeding gums.
  30. Back Rub/Massage
    • 1. Pour small amount of lotion into palm of hand and rub hands together to warm lotion.
    • 2. Apply with gentle pressure, using both hands from buttocks to back of neck without pulling sick, using long firm strokes.
    • 3. Use short circular strokes across the shoulders using both hands.
    • 4. Perform backrub for 3-5 minutes or as ordered.
    • 5. Assess skin condition.
    • 6. When asked by examiner verbalize actions needed if redness or skin break down are noticed.
  31. Foot/Toenail Care
    • 1. Inspect for cracked, broken nails/skin and between toes.
    • 2. Do not clip toenails.
    • 3. Soak feet in warm water.
    • 4. Dry feet completely including between toes.
    • 5. APply lotion if desired, but not between toes.
    • 6. Apply socks/shoes.
    • 7. Report abnormalities.
  32. Dressing/Undressing Resident
    (Must Dress and Undress)
    • 1. Demonstrate how to properly dress/undress resident with hemiplegia.
    • 2. Provide privacy during entire procedure.
    • 3. Dress weak side first.
    • 4. Undress weak side last.
  33. Shaving (Simulate)
    • 1. Pplace towel to protect resident's clothing (electric/blade).
    • 2. Soften beard with warm washcloth and apply shaving cream (blade).
    • 3. Gently pull skin taut. (electric/blade)
    • 4. Use short strokes of razor in the direction the hair is growing (electric/blade).
    • 5. Rinse razor often (blade).
    • 6. Rinse and dry resident's face.
    • 7. Apply after shave if desired.
    • 8. Dispose blade in sharps container.
  34. Provide Peri-Care (Stimulate Male or Female Examiners Choice)
    • Female:
    • 1. Assist resident in removing clothing, only as necessary, exposing only area being washed.
    • 2. Provide privacy (remembering dignity).
    • 3. Obtain bath basin with water of a safe and comfortable temperature.
    • 4. Cleanse labia (inside then outside) and all skin folds from front to back (clean to dirty) with soapy wash cloth.
    • 5. Rinse and gently dry each are thoroughly after washing.
    • 6. Clean the anal area from front to back.
    • 7. Rinse and gently dry each area thoroughly after washing.
    • 8. Redress resident.

    • Male:
    • 1. Assist resident in removing clothing, only as necessary, exposing only area being washed.
    • 2. Provide privacy (remembering dignity).
    • 3. Obtain bath basin with water of a safe and comfortable temperature.
    • 4. Cleanse penis from tip to base (clean to dirty) with soapy wash cloth. If male is uncircumcised retract the foreskin by gently pushing the skin toward the base of the penis and clean as directed above.
    • 5. rinse and gently dry each area thoroughly after washing.
    • 6. Clean the anal area from front to back.
    • 7. Rinse and gently dry each area thoroughly after washing.
    • 8. Redress resident
  35. Assisting with a Bedpan/Fracture Pan
    • 1. Position the bedpan/fracture pan under the patient correctly (if using a fracture pan, the flat side should be toward the back of the patient).
    • 2. Raise head of bed to a comfortable level.
    • 3. Place tissue within reach of resident.
    • 4. Position call light within reach of the resident.
    • 5. Provide privacy.
    • 6. Gently remove bedpan.
    • 7. Provide or assist with peri-care as needed.
    • 8. Empty bedpan in toilet.
    • 9. Rinse, dry and store bedpan in proper location.
    • 10. Washes/assists resident to wash and dry hands.
    • 11. Record results accurately.
  36. Collectin a Stool Speciman
    • 1. Properly label specimen container with residents name, DOB, date and time of speciman collection and type of specimen.
    • 2. Using a tongue depressor take a sampe of feces from the bedpan or specimen collection device.
    • 3. Note color, amount and quality of feces.
    • 4. Dispose of tonguq depressor in a disposable bag.
    • 5. Empty remaining contents of bedpan or specimen collection device into toilet.
    • 6. Put lid tightly on the specimen cup.
    • 7. Place specimen cup into transport bag.
    • 8. Wash hands.
    • 9. Take the specimen cup to the designated location.