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1. Turns on water.
2. Wets hands.
3. Applies skin cleanser or soap to hands.
4. RUBS HANDS ToGETHER FoR AT LEAST
10 SECONDS.
5. Wash all surfaces of the hand at least up to the wrist
6. Rinses hands thoroughly under running water.
7. Dries hands on clean towel/warm air dryer.
8. Turns off faucet w/ towel and/or avoid contact with sink or other dirty surfaces during rinsing and drying of the hands.
9. Discards wet towel appropriately.
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How to Start Conversation and
Send Messages
|
1. Greets resident by preferred name.
2. Identifies self to resident.
3. Focuses on the appropriate topic to be presented. 4. Faces the resident to speak and avoids talking off into space. 5. Talks with resident while giving care
6. Listens and responds appropraitly when resident speak
7. Uses social reinforcers such as praise & smiles. 8. Encourages resident to interact with nurse aide and others. 9. Use courtesy when communicating
10. Informs resident before leaving room.
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Communicating with Residents
Who Have Vision Loss
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1. To avoid startling the resident, KNOCK on the door before entering and identify your self upon entering the room. 2. Positions self in good light and faces resident when speaking.
3. Greet resident by prefered name using touch such as pat on the arm or holding hand as appropriate.
4. Talks with resident while giving care,
also giving step by step explination as
appropriately of what you are doing.
5. Explains what the resident is to do.
6. Listen attentively and clarifies residents understanding as appropriate
7. Inform resident before leaving the room
8. Use courtesy when communicating.
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Communicating with Residents
Who Have Hearing Loss
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1. Alerts resident to presence by approaching from the front or side. 2. Positions self in good light and faces resident while speaking. 3. Greets resident by preferred name.
4. Identifies self to resident.
5. Talks with resident while giving care.
6. Speaks in a lower pitched voice at a normal or slightly increased loud-avoid shouting as appropriate
7. Listens attenitively and clarifies resident understanding as appropriate
8. Use courtesy when communicating
9. Informs resident before leaving room.
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Communicating With Residents
Who Have Problems With Speech
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1. Greets resident by preferred name.
2. Identifies self to resident.
3. TALKS WITH RESIDENT WHILE GIVING
CARE.
4. GIVES RESIDENT ADEqUATE TIME To
RESPoND, LISTENING ATTENTIVELY.
5. Encourages and assists resident with the use of
assistive devices for communication, such as picture
board and word boards, if necessary.
6. Clarifies resident’s understanding as appropriate.
7. USES CoURTESY WHEN
CoMMUNICATING.
8. Informs resident before leaving the room.
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Assisting Residents Who Have
Memory Loss, Confusion or
Understand Problems
|
Greets resident by preferred name.
2. Identifies self to resident.
3. TALKS WITH RESIDENT WHILE GIVING
CARE, GIVING SIMPLE STEP-BY-STEP
INSTRUCTIoN AS APPRoPRIATE.
4. PRoNoUNCES WoRDS CLEARLY AND
SLoWLY.
5. Promotes resident’s independence.
6. LISTENS AND RESPoNDS APPRoPRIATELY
WHEN RESIDENT SPEAKS.
7. Provides some orientation to resident with mild
memory loss as appropriate.
8. Continues to call resident by name during
conversation.
9. USES CoURTESY WHEN
CoMMUNICATING.
10. Informs resident before leaving room
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Assisting Resident Who Is
Demanding or Angry
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1. Greets resident by preferred name.
2. Identifies self to resident.
3. TALKS WITH RESIDENT WHILE GIVING
CARE AS APPRoPRIATE.
4. REMAINS CALM.
5. Encourages resident to talk about concerns as
appropriate.
6. LISTENS ATTENTIVELY AS RESIDENT
SPEAKS.
7. USES CoURTESY WHEN
CoMMUNICATING.
8. Informs resident before leaving room.
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Moving the Helpless Resident to the
Head of the Bed with one Assistant
(Using Draw Sheet or
Incontinent Pad)
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Provides for resident’s privacy as appropriate.
4. INSURES RESIDENT’S SAFETY.
5. Lowers the head of the bed as flat as possible if
tolerated by resident.
6. Places pillow against headboard before moving
resident, to protect resident’s head.
7. Exhibits proper body mechanics.
8. Gives directions and coordinates moves with
assistant.
9. USING DRAW SHEET oR INCoNTINENT
PAD MoVES THE RESIDENT To THE HEAD
oF THE BED, PREVENTING TRAUMA AND
AVoIDABLE PAIN.
10. Leaves resident in a position of comfort, replacing
pillow under head, if appropriate.
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Assisting Resident to Sit Up
on Side of Bed
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Provides for resident’s privacy as appropriate.
4. INSURES RESIDENT’S SAFETY.
5. Rolls head of bed to upright position.
6. Exhibits proper body mechanics.
7. SAFELY SUPPoRTS AND TURNS THE
RESIDENT, ALLoWING THE LEGS To
Go oVER THE SIDE oF THE BED AS THE
TRUNK BECoMES UPRIGHT.
8. PREVENTS TRAUMA AND AVoIDABLE
PAIN To THE RESIDENT DURING MoVE.
9. REMAINS WITH RESIDENT WHILE HE/SHE
SITS oN SIDE oF BED AS APPRoPRIATE.
10. Leaves resident in a position of comfort.
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Assisting the Resident
to Transfer from Chair to Bed
or Bed to Chair
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Properly cleans hands before procedure as
appropriate.
2. Assembles appropriate equipment before procedure.
3. Explains procedure to resident and encourages
resident to participate as appropriate.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Obtains assistance if needed and exhibits proper
body mechanics.
7. Places chair or wheelchair near the bed if
appropriate.
8. LoCKS WHEELS IF PoSSIBLE
oR STABILIZES BoTH BED AND
WHEELCHAIR.
9. Assists resident into sitting position and allow
resident to rest in sitting position before standing, if indicated.
10. SAFELY TRANSFERS RESIDENT,
SUPPoRTING RESIDENT DURING
PRoCEDURE.
11. PREVENTS TRAUMA AND AVoIDABLE
PAIN To RESIDENT DURING PRoCEDURE.
12. Leaves resident in a position of comfort.
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Assisting the Resident
With Ambulation
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages resident to
participate as appropriate.
3. ASSEMBLES APPRoPRIATE EqUIPMENT
BEFoRE PRoCEDURE INCLUDING
AMBULATIoN AIDS SUCH AS CANE,
WALKER oR GAIT BELT IF USED BY
RESIDENT.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Obtains assistance if needed and exhibits proper
body mechanics.
7. SAFELY ASSISTS RESIDENT To STANDING
PoSITIoN.
8. Walks slightly behind and to one side of ambulating
resident.
9. SUPPoRTS RESIDENT AS NEEDED DURING
AMBULATIoN To AVoID FALLS AND
TRAUMA.
10. Leaves resident in a position of comfort
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Making the Unoccupied Bed
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1. Properly cleans hands before procedure as
appropriate.
2. Assembles appropriate equipment and places it in
the appropriate place.
3. Begins with bed in flat position and elevated to
appropriate height if possible. Lowers bed when
completed.
4. REMoVES SoILED LINEN AND PLACES IT
IN APPRoPRIATE PLACE.
Skill continues 5. Avoids shaking and touching linen to uniform as
much as possible.
6. Applies bottom sheet to clean mattress, keeping it
straight and centered.
7. MAKES ALL CLEAN BoTToM LINEN
TIGHT AND FREE oF WRINKLES
(UNLESS WATER BED, EGG CRATE oR AIR
MATTRESS.)
8. APPLIES ToP LINEN.
9. Applies clean pillowcase to the pillow, keeping
zippers and/or tags on the pillow to the inside of the
pillowcase.
10. Leaves bed completely and neatly made according to
facility policy.
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure
and places it in appropriate place.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Begins with the bed in flat position, if tolerated by
resident and elevated appropriate height if possible.
7. RAISES SIDE RAIL AND ASSISTS RESIDENT
To RoLL oN SIDE FACING SIDE RAIL.
8. Rolls or fan folds soiled linen, soiled side inside, to
the center of the bed.
9. Places clean bottom sheet along the center of the
bed and rolls or fanfolds linen against resident’s back
and unfolds remaining half.
10. RAISES THE oPPoSITE SIDE RAIL AND
ASSISTS THE RESIDENT To RoLL oVER THE
BoTToM LINEN, PREVENTING TRAUMA
AND AVoIDABLE PAIN To RESIDENT.
11. REMoVES SoILED LINEN AND PLACES IN
APPRoPRIATE PLACE.
12. Avoids shaking and touching linen to uniform as
much as possible.
27
Skill continues 13. MAKES ALL CLEAN BoTToM LINEN
TIGHT AND FREE oF WRINKLES
(UNLESS WATER BED, EGG CRATE oR AIR
MATTRESS.)
14. APPLIES UNSoILED ToP LINEN.
15. Applies clean pillowcase with zippers and/or tags to
inside, gently lifting resident’s head to replace pillow.
16. Leaves resident in position of comfort in a neatly
made bed.
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Tub or Shower Bath with
Shampooing the Hair
|
1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT SAFETY.
6. Assists resident to undress as needed.
7. REGULATES TEMPERATURE AND FLoW
oF WATER PRIoR To AND DURING
SHoWER oR BATH AND SHAMPoo.
8. Positions resident to shampoo hair, offering
washcloth to protect the eyes.
9. Directs warm water close to scalp and away from
face.
10. Applies appropriate shampoo, works up lather,
and massages into scalp using tips of fingers/not
fingernails.
11. Rinses hair thoroughly and towel dries.
12. WASHES, RINSES AND DRIES BoDY
FRoM CLEAN To DIRTY AREAS, LEAVING
RESIDENT CLEAN AND DRY.
13. Reports any deviations from the norm. (Nurse Aide
Evaluator asks aide for report)
14. Leaves resident in position of comfort
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Perineal Care/Incontinent Care– Female With or Without
Catheter
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. If indwelling catheter present, holds and supports
catheter tubing to one side to avoid traction or
unnecessary movement during procedure.
7. If indwelling catheter present, when cleaning urethral
area, gently washes, rinses, and dries the catheter
tubing from urethra outward for about three inches
of tubing.
8. If indwelling catheter present, keeps drainage bag
below level of bladder.
9. First separates labia and gently washes, rinses, and
dries, as appropriate, the urethral area, wiping from
front to back and avoiding the rectum.
10. Then washes, rinses and dries, as appropriate, the
remaining perineal area, wiping from front to back
and working outward to thighs.
11. Turns resident on side and appropriately and gently
washes, rinses and dries the remaining area including
the rectum and buttocks without returning to the
urethral area.
12. APPRoPRIATELY AND GENTLY WASHES,
RINSES AND DRIES FRoM CLEAN To
DIRTY AREA LEAVING ENTIRE AREA
CLEAN AND DRY.
13. Removes soiled linen and places in an appropriate
place.
14. Leaves resident in position of comfort.
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Perineal Care/Incontinent Care–
Male With or Without
Catheter
|
1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. If uncircumcised male, retracts foreskin before and
replaces foreskin after procedure.
7. If indwelling catheter present, holds and supports
catheter tubing to one side to avoid traction or
unnecessary movement during procedure.
8. If indwelling catheter present, when cleaning
urethral area, appropriately and gently washes, rinses
and dries the catheter tubing from urethra outward
for about 3 inches of tubing.
9. If indwelling catheter present, keeps drainage bag
below level of bladder.
10. Appropriately and gently washes, rinses and dries
the tip of the penis, starting at urethra first and
working outward in a circular motion.
11. Then washes, rinses and dries the entire perineal
area including the penis, scrotum and outward to
thighs.
12. Turns resident on side and appropriately and gently
washes, rinses and dries the remaining area including
the rectum and buttocks without returning to the
urethral area.
13. APPRoPRIATELY AND GENTLY WASHES,
RINSES, AND DRIES FRoM CLEAN To
DIRTY AREA LEAVING ENTIRE AREA
CLEAN AND DRY.
14. Removes soiled linen and places in an appropriate
place.
15. Leaves resident in position of comfort.
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. PoSITIoNS RESIDENT UPRIGHT oR oN
SIDE WITH HEAD TURNED WELL To
oNE SIDE AS APPRoPRIATE To AVoID
CHoKING oR ASPIRATIoN.
7. Drapes the chest as needed to prevent soiling.
8. Applies or assists/supervises resident in applying
toothpaste to toothbrush.
9. GENTLY AND THoRoUGHLY BRUSHES
oR ASSISTS/SUPERVISES RESIDENT IN
BRUSHING TEETH, INCLUDING THE
INNER, oUTER AND CHEWING SURFACES
oF ALL UPPER AND LoWER TEETH.
10. Cleans tongue if appropriate.
11. Assists or supervises resident in rinsing mouth.
12. Leaves resident in position of comfort.
13. Reports all deviations from the norm. (Nurse Aide
Evaluator asks nurse aide for report.)
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Positions resident upright or on side with head
turned well to one side as appropriate to avoid
choking or aspiration.
7. Removes or assists/supervises resident in removing
dentures from mouth or storage container.
8. Handles dentures carefully to avoid damage. 9. THoRoUGHLY BRUSHES DENTURES,
INCLUDING THE INNER, oUTER AND
CHEWING SURFACES oF UPPER AND
LoWER DENTURES.
10. RINSES DENTURES USING CLEAN WATER.
(DoES NoT USE HoT WATER.)
11. Assists or supervises resident in cleaning or rinsing
mouth.
12. Replaces or assists/supervises in replacing dentures
in resident’s mouth or into clean denture cup.
13. Leaves resident in position of comfort.
14. Reports all deviations from the norm. (Nurse Aide
Evaluator asks nurse aide for report.)
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Mouth Care of
Dependent Resident
|
1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. PoSITIoNS RESIDENT UPRIGHT oR oN
SIDE WITH HEAD TURNED WELL To
oNE SIDE AS APPRoPRIATE To AVoID
CHoKING oR ASPIRATIoN.
7. Drapes chest/bed as needed to prevent from soiling.
8. Uses applicators or soft toothbrush and cleaning
solutions according to facility policy.
9. GENTLY AND THoRoUGHLY CLEANS
INSIDE oF MoUTH INCLUDING THE
GUMS, ToNGUE, AND THE INNER, oUTER
AND CHEWING SURFACES oF ALL UPPER
AND LoWER TEETH.
10. Leaves resident in position of comfort.
11. Reports all deviations from the norm.
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Shaving the Male Resident–
Safety or Disposable Razor
|
1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Provides adequate lighting.
7. Drapes chest appropriately to prevent soiling.
8. Wets face with warm water then appropriately
applies shaving soap or cream to bearded areas.
9. ENCoURAGES RESIDENT To MAKE SKIN
TAUT, oR PULLS SKIN TAUT WITH FREE
HAND To AVoID CUTTING FACE.
10. USES SHoRT AND EVEN STRoKES UNTIL
SHAVED.
11. Removes excess shaving cream or soap as
appropriate.
12. Leaves resident shaved and in a position of comfort.
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Shaving the Male Resident–
Electric Razor
|
1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Provides adequate lighting.
7. Encourages resident to make skin taut or pulls skin
taut with free hand.
8. SHAVES WHISKERS USING UP AND DoWN
oR CIRCULAR MoTIoNS UNTIL SHAVED.
9. Leaves resident shaved and in a position of comfort
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Provides adequate lighting.
7. Immerses nails in comfortable warm water and
soaks for at least five (5) minutes. (If resident just
completed shower or tub bath no additional soaking
is necessary.)
8. Gently cleans under nails with file, orange stick or
nailbrush. (Nails may be cleaned as they soak.)
9. Dries hands thoroughly, being careful to dry
between fingers.
10. Gently pushes cuticle back with towel or orange
stick.
11. CUTS FINGERNAILS STRAIGHT ACRoSS
oR SLIGHTLY oVAL AND EVEN WITH
oR SLIGHTLY ABoVE END oF FINGERS,
WITHoUT CAUSING TRAUMA oR
AVoIDABLE PAIN.
12. Smooth rough edges of nails with nail file or emery
board, shaping as appropriate.
13. Leaves resident in position of comfort with
fingernails smooth and clean.
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oral Temperature/Pulse/
Respirations
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Oral Temperature:
1. Cleans hands appropriately before procedure.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. PREPARES THERMoMETER FoR
USE APPRoPRIATELY (IF GLASS
THERMoMETER, SHAKES DoWN
MERCURY To 96 DEGREES oR BELoW)
AND PLACES CoRRECT END oF
THERMoMETER INTo RESIDENT’S
MoUTH, UNDER ToNGUE.
7. LEAVES THERMoMETER IN PLACE
FoR APPRoPRIATE LENGTH oF TIME
WITH LIPS CLoSED, (IF MERCURY
THERMoMETER, THREE MINUTES.)
8. Records the temperature reading. (Evaluator should
ask nurse aide to do this step.) (Instructions to
Nurse Aide Evaluator: Read thermometer AFTER
nurse aide does and record both readings on the Nurse
Aide Skills Examination Performance Summary
Sheet.)
9. NURSE AIDE’S RECoRDED TEMPERATURE
VARIES No MoRE THAN 0.2 DEGREES
FRoM EVALUAToR’S RECoRDED
TEMPERATURE.
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10. LoCATES THE RADIAL PULSE BY PLACING
TIPS oF FINGERS oN THUMB SIDE oF THE
RESIDENT’S WRIST.
11. CoUNTS PULSE FoR 30 SECoNDS TIMES 2
oR FoR 60 SECoNDS, USING A TIMEPIECE.
(NURSE AIDE EVALUAToR SHoULD ASK
NURSE AIDE LENGTH oF TIME SHE/HE
CoUNTED.)
12. Records pulse rate. (Nurse Aide Evaluator: Check
resident’s pulse rate, using same wrist, AFTER nurse
aide does and record both rates on the Nurse Aide
Skills Examination Performance Summary Sheet.)
35
Skill continues 13. NURSE AIDE’S RECoRDED PULSE
RATE IS WITHIN 10% oF NURSE AIDE
EVALUAToR’S RECoRDED RATE.
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14. CoUNTS AND RECoRDS RESIDENT’S
RESPIRATIoNS FoR 30 SECoNDS TIMES 2
oR FoR 60 SECoNDS, USING A TIMEPIECE.
(NURSE AIDE EVALUAToR SHoULD ASK
NURSE AIDE FoR LENGTH oF TIME SHE/
HE WILL CoUNT AND CHECK RESIDENT’S
RESPIRATIoNS WHILE NURSE AIDE DoES,
RECoRDING BoTH RATES oN THE NURSE
AIDE ExAMINATIoN PERFoRMANCE
SUMMARY SHEET.)
15. NURSE AIDE’S RECoRDED RESPIRAToRY
RATE IS WITHIN 20% oF NURSE
EVALUAToR’S RECoRDED RATE.
16. Leaves resident in position of comfort.
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Axillary Temperature/Pulse/
Respirations
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Axillary Temperature:
1. Cleans hands appropriately before procedure.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. PREPARES THERMoMETER FoR
USE APPRoPRIATELY (IF GLASS
THERMoMETER, SHAKES DoWN
MERCURY To 96 DEGREES oR BELoW)
AND PLACES CoRRECT END oF
THERMoMETER IN THE HoLLoW oF THE
ARMPIT.
7. HoLDS THERMoMETER IN PLACE FoR
APPRoPRIATE LENGTH oF TIME, TEN (10)
MINUTES IF MERCURY THERMoMETER,
HoLDING RESIDENT’S ARM CLoSE To
HIS/HER BoDY. 8. Records the temperature reading, placing an “Ax”
to indicate Axillary temperature. (Nurse Aide
Evaluator should ask nurse aide to record the
reading.) (Instructions to Nurse Aide Evaluator:
Read thermometer after nurse aide does and record
both readings on the Nurse Aide Skills Examination
Performance Summary Sheet.)
9. NURSE AIDE’S RECoRDED TEMPERATURE
VARIES No MoRE THAN 0.2 DEGREES
FRoM EVALUAToR’S RECoRDED
TEMPERATURE.
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10. LoCATES THE RADIAL PULSE BY PLACING
TIPS oF FINGERS oN THUMB SIDE oF THE
RESIDENT’S WRIST.
11. CoUNTS PULSE FoR 30 SECoNDS TIMES 2
oR FoR 60 SECoNDS, USING A TIMEPIECE.
(NURSE AIDE EVALUAToR SHoULD ASK
NURSE AIDE FoR LENGTH oF TIME SHE/
HE CoUNTED.)
12. Records pulse rate. (Nurse Aide Evaluator: Check
resident’s pulse rate, using same wrist, AFTER nurse
aide does and record both rates on the Nurse Aide
Skills Examination Performance Summary Sheet.)
13. NURSE AIDE’S RECoRDED PULSE
RATE IS WITHIN 10% oF NURSE AIDE
EVALUAToR’S RECoRDED RATE.
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14. CoUNTS AND RECoRDS RESIDENT’S
RESPIRATIoNS FoR 30 SECoNDS TIMES 2
oR FoR 60 SECoNDS, USING A TIMEPIECE.
(NURSE AIDE EVALUAToR SHoULD ASK
NURSE AIDE FoR LENGTH oF TIME SHE/
HE WILL CoUNT AND CHECK RESIDENT’S
RESPIRATIoNS WHILE NURSE AIDE
DoES, RECoRDING BoTH RATES oN
THE NURSE AIDE SKILLS ExAMINATIoN
PERFoRMANCE SUMMARY SHEET.)
15. NURSE AIDE’S RECoRDED RESPIRAToRY
RATE IS WITHIN 20% oF NURSE AIDE
EVALUAToR’S RECoRDED RATE.
16. Leaves resident in position of comfort.
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Rectal Temperature/Pulse/
Respirations
|
1. Cleans hands appropriately before procedure.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. PREPARES THERMoMETER FoR
USE APPRoPRIATELY (IF GLASS
THERMoMETER, SHAKES DoWN
MERCURY To 96 DEGREES oR
BELoW.) APPLIES SMALL AMoUNT
oF LUBRICANT oN BULB oF RECTAL
THERMoMETER IF NoT PRELUBRICATED
AND GENTLY INSERTS CoRRECT END
oF THERMoMETER INTo RECTUM
APPRoxIMATELY oNE INCH.
7. HoLDS THERMoMETER IN PLACE
FoR APPRoPRIATE LENGTH oF TIME,
(THREE (3) MINUTES IF MERCURY
THERMoMETER.)
8. Records the temperature reading, placing an
“R” to indicate rectal temperature. (Nurse Aide
Evaluator should ask nurse aide to record reading.)
(Instructions to Nurse Aide Evaluator: Read
thermometer AFTER nurse aide does and record
both readings on the Nurse Aide Skills Examination
Performance Summary Sheet.)
9. NURSE AIDE’S RECoRDED TEMPERATURE
VARIES No MoRE THAN 0.2 DEGREES
FRoM EVALUAToR’S RECoRDED
TEMPERATURE.
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LoCATES THE RADIAL PULSE BY PLACING
TIPS oF FINGERS oN THUMB SIDE oF THE
RESIDENT’S WRIST.
38
Skill continues 11. CoUNTS PULSE FoR 30 SECoNDS TIMES 2
oR FoR 60 SECoNDS, USING A TIMEPIECE.
(NURSE AIDE EVALUAToR SHoULD ASK
NURSE AIDE FoR LENGTH oF TIME SHE/
HE CoUNTED.)
12. Records pulse rate. (Nurse Aide Evaluator: Check
resident’s pulse rate, using same wrist, AFTER nurse
aide does and record both rates on the Nurse Aide
Skills Examination Performance Summary Sheet.)
13. NURSE AIDE’S RECoRDED PULSE
RATE IS WITHIN 10% oF NURSE AIDE
EVALUAToR’S RECoRDED RATE.
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14. CoUNTS AND RECoRDS RESIDENT’S
RESPIRATIoNS FoR 30 SECoNDS TIMES 2
oR FoR 60 SECoNDS, USING A TIMEPIECE.
(NURSE AIDE EVALUAToR SHoULD ASK
NURSE AIDE FoR LENGTH oF TIME
HE/SHE WILL CoUNT AND CHECK
RESIDENT’S RESPIRATIoNS WHILE NURSE
AIDE DoES. RECoRDING BoTH RATES oN
THE NURSE AIDE SKILLS ExAMINATIoN
PERFoRMANCE SUMMARY SHEET.)
15. NURSE AIDE’S RECoRDED RESPIRAToRY
RATE IS WITHIN 20% oF NURSE AIDE
EVALUAToR’S RECoRDED RATE.
16. Leaves resident in position of comfort.
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1. Properly cleans hands appropriately before
procedure.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure
such as correct sized cuff.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. Provides adequate lighting.
7. Assists resident into a comfortable sitting or
recumbent position with forearm relaxed and
supported in a palm-up position, approximately at
the level of the heart.
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Skill continues 8. Rolls resident’s sleeve up about 5 inches above the
elbow and applies the cuff around the upper arm
just above the elbow.
9. Cleans earpieces of stethoscope appropriately and
places in ears.
10. LoCATES BRACHIAL ARTERY, PLACES
STETHoSCoPE oVER BRACHIAL ARTERY
AND HoLDS SNUGLY IN PLACE WITHoUT
ToUCHING CUFF, oR FEELS BRACHIAL
PULSE WITH FINGERS WHILE INFLATING
CUFF.
11. Tightens valve attached to air bulb.
12. Quickly pumps air into cuff to about 20 mm to 30
mm above the point where pulse ceased to be detected.
(Places stethoscope over brachial artery now, if not done
at step #10.)
13. Opens valve on air bulb, letting air escape slowly
and evenly, while watching gauge and listening for
pulse sounds. Notes the systolic pressure (when
the first regular sound is heard) and the diastolic
pressure (when the pulse changes from a loud beat
to a faint murmur, or if no change is heard, until
the sound disappears.)
14. Records the systolic and diastolic blood pressure.
(Instructions to Evaluator: Ask nurse aide to record
blood pressure, then the Nurse Aide Evaluator checks
blood pressure in same arm and records results on the
Nurse Aide Skills Examination Performance Summary
Sheet. Use teaching stethoscope if available.)
15. NURSE AIDES RECoRDED BLooD
PRESSURE READING (BoTH SYSToLIC
AND DIASToLIC) VARIES No MoRE
THAN 10 MM HG FRoM NURSE AIDE
EVALUAToR’S BLooD PRESSURE
MEASUREMENT.
16. Removes blood pressure cuff and leaves resident in a
position of comfort.
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Weight of Ambulatory
Resident
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. INSURES RESIDENT’S SAFETY.
6. ASSURES THAT SCALE IS IN BALANCE
BEFoRE WEIGHING RESIDENT.
7. CHECKS THAT RESIDENT IS BALANCED
AND CENTERED oN SCALE WITH ARMS
AT SIDES AND NoT HoLDING oN To
ANYTHING THAT CoULD ALTER READING
oF THE WEIGHT.
8. Properly adjusts weights until scale is in balance.
9. Reads weight and reports it to the Nurse Aide
Evaluator.
(Nurse Aide Evaluator: Read weight of resident
WHILE the nurse aide does and record both weights
on the Nurse Aide Skills Examination Performance
Summary Sheet.)
10. NURSE AIDE’S RECoRDED WEIGHT
VARIES No MoRE THAN 2 LBS. FRoM
NURSE AIDE EVALUAToR’S READING.
11. Leaves resident in position of comfort.
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Range of Motion (RoM)–
Exercise for Right or Left
Upper Extremity
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Provides for resident’s privacy as appropriate.
4. Insure resident safety, such as: SUCH AS
stopping excercise immediately is any pain or discomfort occurs and notify charge nurse if pain is sharp or unexpectected
5. Positions resident supine and in good body
alignment.
6. Move joints gently, smoothly and slowly through the range of motion to the point of resistance as tolerated by resident
7. Gently support arm and elbow and wrist 8. Beginning with arm straight at side, flex elbow and brings arm over head as far as possible, then return arm to side of body x3.
9. Beginning with arm straight at side, moves straight arm out at a right angle to body, then returns straight arm to side x3.
10. (Optional step) With resident standing or sitting, moves arm slightly behind body, then returns arm to side x3. (If this step is not performed by nurse aide,
score NA.)
11. Beginning with arm at side, flexes elbow and moves
hand toward shoulder then straightens arm x3.
12. With arm flat on bed, turns hand so palm is up,
then turns hand so palm is down x3.
13. GENTLY SUPPoRTS WRIST AND HAND.
14. With palm up, flexes wrist toward shoulder then
extends wrist x3.
15. Moves hand side to side at wrist toward thumb then
toward little finger x3.
16. Places fingers over resident’s fingers and curls
resident’s fingers to form fist, then straightens
resident’s fingers out x3.
17. Touches resident’s thumb to each finger x3.
18. Moves each finger and thumb away from middle
finger, then moves each finger and thumb toward
middle finger x3.
19. Leaves resident in a position of comfort.
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Range of Motion (RoM)– Exercise for Right or Left Lower Extremity
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages resident to participate as appropriate.
3. Provides for resident’s privacy as appropriate.
4. Insures resident safety,such as stopping excercise immediatly if any pain or discomfort occurs and notify charge nurse if pain is sharp and unexpected 5. Positions resident supine and in good body
alignment.
6. Moves gently, smoothly and slowly through the range of motion to the point of resistence as tolerated
7. Gently support leg at knee and ankle 8. Beginning with leg straight, flexes the knee and
slowly raises the leg, then straightens the knee and
lowers the leg x3.
9. Beginning with leg straight, moves straight leg away
from center of body then moves straight leg back
toward center x3.
10. With leg straight, turns leg inward, then turns leg
outward x3.
11. GENTLY SUPPoRTS ANKLE AND FooT.
12. Moves forefoot in clockwise circles, and counter
clockwise circles x3.
13. Places fingers over resident’s toes and curls toes
down, then straightens toes x3.
14. Moves each toe away from the middle toe, then
moves each toe toward middle toe x3.
15. Leaves resident in position of comfort.
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Assisting the Totally Dependent Resident With Dressing, Hair Combing, and Application of Prosthetic Devices
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1. Properly cleans hands before procedure as appropriate. 2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. Insures resident safety 6. Encourages resident to select his/her own clothing as appropriate. 7. Gently and naturally moves body parts to avoid forcing or over extending limbs, joints or to prevent trauma and avoiding pain. 8. Dresses resident in an organized manner to prevent undue exertion. 9. Combs resident’s hair including back of head, and arranges it according to resident’s preference. 10. Assist resident to put on desired prosthetic device(s) as needed, i.e., eyeglasses,hearing aid, and dental devices. 11. Leaves resident in a position of comfort.
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure and places it in appropriate place.
4. Provides for resident’s privacy as appropriate.
5. Insures resident safety
6. Checks water for comfortable temperature.
7. Wets washcloth, applies soap (if resident desires) and supervises/assists resident in washing, rinsing (if soap is used) and drying face, ears and neck.
8. Supervises/assists resident in washing, rinsing, and drying arms and hands, thoroughly drying between fingers.
9. Supervises/assists resident in washing, rinsing, and drying chest and abdomen. 10.Supervises/assists resident in washing, rinsing, and drying legs and feet, thoroughly drying between toes. 11.Changes bath water in basin at least prior to washing the back and as needed during bath to keep water reasonable warm, clean and free of excess soap. 12. Washes, rinses, and dries back of neck, back and buttocks. 13. Supervises/assists resident with properly washing, rinsing and drying perineal area or provides privacy if resident is able to wash perineum without assistance.
14.Wash, Rinse and Dries from clean to dirty areas
15. Reports all deviations from the norm
16. Leaves resident clean and in a position of comfort
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Feeding the Dependent Resident
(offering Food and Fluids)
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages
resident to participate as appropriate.
3. Assembles appropriate equipment before procedure.
4. Provides for resident’s privacy as appropriate.
5. Insures resident safty
6. Position resident upright at least 45 degrees or on side to avoid chocking or aspiration
7. Protects clothing from soiling such as by using napkin or bib.
8. Washes resident’s hands and face before feeding as needed.
9. Describes the foods being offered.
10. Assures the safe temperature of food to avoid burns.
11. Allows resident to feed self as much as possible to increase independence.
12. Offers fluid after every third or fourth bite.
13. Offer foods in small amounts at a reasonable rate, allowing resident to chew and swallow
14. Wipes resident’s hands and face during meal as needed.
15. Leaves resident clean and in position of comfort.
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Turning the Resident
on His Side Toward You
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1. Properly cleans hands before procedure as
appropriate.
2. Explains procedure to resident and encourages resident to participate as appropriate.
3. Provides for resident’s privacy as appropriate.
4. Insure's resident safety
5. Exhibits proper body mechanics.
6. Positions resident to assist in turning.
7. Gently roll the resident on his/her side toward you wih out trama and/or avoiding pain.
8. Leaves resident in position of comfort and in good body alignment, using supports as needed to maintain the side-lying position.
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