Fundamental 2 New Checklist

‫اململكة العربية السعودية‬
KINGDOM OF SAUDI ARABIA

Ministry Of Education ‫وزارة التعليم‬
King Khalid University ‫جامعة الملك خالد‬
Nursing College ‫كلية التمريض‬
Procedure Manual
Fundamentals of Nursing II
NURS 211 (Practical Checklists)
Dr.Zainab Albikawi RN,MSN, PhD

Assistant Professor
References:
 Kozier, B., Erb, G., Berman, A. & Burke, K. (2015). Fundamentals of Nursing. (10th ed.). Simione, V,
New Jersey.
 Lynn, P.(2011). Skill Checklists to Accompany Taylor's Clinical Nursing Skills, A Nursing Process
Approach, 3rd ed., Philadelphia, Lippincott Williams & Wilkins.
Table of Contents
1. Aseptic techniques (Surgical hand scrub not included)
 Skill 1-1: Medical Hand Washing (Soap and Water).
 Skill 1-2: Hand Hygiene (Alcohol-Based Hand Rub).
 Skill 1-3: Establishing and maintaining a sterile field.
 Skill 1-4: Applying and Removing Personal Protective Equipment (Gloves, Gown, Mask, and Eyewear).
2. Vital signs
 Skill 2-1: Assessing body temperature.
 Skill 2-2: Assessing the radial pulse.
 Skill 2-3: Assessing the respiratory rate.
 Skill 2-4: Assessing blood pressure
3. Nursing process
4. Bed making, positioning, transferring
 Skill 4-1: Making an Unoccupied Bed.
 Skill 4-2: Making an Occupied Bed
 Skill 4-3: Turning and moving a client.
 Skill 4-4: Transferring a client.
5. Nutrition
 Skill 5-1: Inserting a nasogastric tube
 Skill 5-2: Removing a nasogastric tube
 Skill 5-3: Administering Medications via a nasogastric tube.
6. Body hygiene
 Skill 6-1: Giving a bed bath.
 Skill 6-2: Giving Oral Care to Unconscious Clients
7. Elimination
 Skill 7-1: Collecting an Urine Specimen
 Skill 7-2: Collecting stool specimen.
 Skill 7-3: Catheterization the female urinary bladder.
 Skill 7-4: Administering A Cleansing Enema
8. Preparation of medication
 Skill 8-1: Administering Oral Medications
 Skill 8-2: Instilling Eye Medications.
 Skill 8-3: Administering Nasal Medications.
 Skill 8-4: Instilling Ear Drops
 Skill 8-5: Administering Intradermal Injections
 Skill 8-6: Administering Subcutaneous Injections.
 Skill 8-7: Administering Intramuscular Injections
 Skill 8-8: Administering a Rectal Suppository.
 Skill 8-9: Initiating a Peripheral Venous Access IV Infusion
9. Oxygenation
 Skill 9-1: Administering oxygen by nasal cannula.
 Skill 9-2: Administering oxygen by oxygen mask.
Skill 2-1:Assessing Body Temperature

NeedsPractice
Excellent
Satisfactory
Goals: Thermometer remained inserted the

appropriate time, level of temperature is
consistent with accompanying signs and
symptoms, thermometer and surrounding tissue
remain intact. Comments
1 0.5 0
Assessment
1. Determine when and how frequently to
monitor the client’s temperature and the
type of thermometer previously used.
2. Review previously recorded temperature
measurements.
If using an oral electronic, digital, or glass
thermometer:
1. Observe the client’s ability to support a
thermometer within the mouth and to
breathe adequately through the nose with
the mouth closed.
2. Read the client’s history for any reference to
recent seizures or a seizure disorder.
3. Determine if the client consumed any hot or
cold substances or smoked a cigarette within
the past 30 minutes.
Planning
1. Arrange to take the client’s temperature as
near to the scheduled routine as possible.
2. Gather supplies including a thermometer,
watch, and probe cover or disposable sleeve
if needed. Include lubricant, paper tissues,

and gloves if using the rectal site or other
route if there is a potential for contact with
body secretions.
3.(Use of gloves is determined on an individual
basis. The virus that causes AIDS has not been
shown to be transmitted through contact with
oral secretions unless they contain blood;
thorough handwashing is always appropriate
after any client contact.)
Implementation
1. Introduce yourself to the client if you
have not done so during earlier contact.
2. Explain the procedure to the client.
3. Wash hands or perform hand antisepsis
with an alcohol rub.
Electronic Thermometer
1. Remove the electronic unit from
the charging base.
2. Select the oral or rectal probe depending
on the intended site for assessment.
3. Insert the probe into a disposable cover
until it locks into place.
Oral method
1. Place the covered probe beneath the tongue to
the right or left of the frenulum (structure that
attaches the underneath surface of the tongue
to the fleshy portion of the mouth).
2. Hold probe in place.
3. Maintain the probe in position until an
audible sound occurs.
4. Observe the numbers displayed on the
electronic unit.
5. Remove the probe and eject the probe cover
into a lined receptacle.
6. Replace the probe in the storage holder
within the electronic unit.
Rectal method
1. Provide privacy.
2. Lubricate approximately 1 inch (2.5
cm) of the rectal probe cover.
3. Position the client on the side with the

upper leg slightly flexed at the hip and
knee (Sims’ position).
4. Instruct the client to breathe deeply.
5. Insert the thermometer
approximately 1.5 inches (3.8 cm) in
an adult, 1 inch(2.5 cm) in a child,
and 0.5 inch (1.25 cm) in an infant.
6. Maintain the probe in position until
an audible sound occurs.
7. Observe the numbers displayed on
the electronic unit.
8. Remove the probe and eject the probe
cover into a lined receptacle.
9. Replace the probe in the storage
holder within the electronic unit.
10. Wipe lubricant and any stool from
around the client’s rectum.
11. Remove and discard gloves, if worn;
wash hands or perform hand
antisepsis with an alcohol rub.
Axillary method
1. Insert the thermometer into the
center of the axilla and lower the client’s arm
to enclose the thermometer between the two
folds of skin.
2. Hold the probe in place.
3. Maintain the probe in position
until an audible sound occurs.
4. Remove the probe and eject the probe
cover into a lined receptacle.
5. Replace the probe in the storage
holder within the electronic unit.
6. Return the electronic unit to its
charging base.
7. Record assessment measurement
on the graphic sheet or flowsheet, or in the
narrative nursing notes.
8. Verbally report elevated or
subnormal temperatures.
Infrared Tympanic Thermometer
1. Remove the thermometer component

from its holding cradle.
2. Inspect the tip of the thermometer for
damage and the lens for cleanliness.
3. Replace a cracked or broken tip; clean the
lens with a dry wipe or lint-free swab
moistened with a small amount of isopropyl
alcohol, and then wipe to remove the alcohol
film.
4. Wait 30 minutes after cleaning with alcohol.
5. Cover the speculum with a disposable
cover until it locks in place.
6. Press the mode button to select the choice
of temperature translation (conversion of
tympanic temperature into an oral, rectal, or
core temperature).
7. Depress the mode button for several
seconds to select either Fahrenheit or
centigrade.
8. Hold the probe in your dominant hand.
9. Position the client with the head turned
90°, exposing the ear with the hand holding
the probe.
10. Wait for display of a “Ready” message.
11. Pull the external ear of adults up and back
by grasping the external ear at its midpoint
with your nondominant hand; for children
1. 6 years and younger, pull the ear down and
back.
12. Insert the probe into the ear, advancing it
with a gentle back-and-forth motion until it
seals the ear canal.
13. Point the tip of the probe in an imaginary
line between the sideburn hair and the
eyebrow on the opposite side of the face.
14. Press the button that activates the
thermometer as soon as the probe is in
position.
15. Keep the probe within the ear until the
thermometer emits a sound or flashing light.
16. Repeat the procedure after waiting
2 minutes if this is the first use of the
tympanic thermometer since it was

recharged.
17. Read the temperature, remove the
thermometer from the ear, and release the
probe cover into a lined receptacle.
18. Record assessment measurement on
the graphic sheet or flowsheet, or in the
narrative nursing notes.
19. Verbally report elevated or
subnormal temperatures.
Document
1. Date and time
2. Degree of heat to the nearest tenth
3. Temperature scale
4. Site of assessment
5. Accompanying signs and symptoms
6. To whom abnormal information was
reported, and outcome of the interaction
TOTAL
Instructor/ Evaluator’s Signature Student’s Signature

Satisfactory
NeedsPractice
Skill 2-2:Assessing The Radial Pulse
Excellent
Goals: Pulse rate remained palpable throughout

the assessment, pulse rate is consistent with the
client’s condition. Comments
1 0.5 0
Assessment
monitor the client’s pulse.
2. Review data collected in previous
assessments of the pulse or abnormalities in
other vital signs.
cardiac or vascular disorders.
4. Review the list of prescribed drugs for any
that may have cardiac effects.
Planning
5.
1. Arrange to take the client’s pulse as near to
2. the scheduled routine as possible.
6.
3. Make sure a watch or wall clock with a
4. second hand is available.
7.
5. Plan to assess the client’s pulse after
6. 5 minutes of inactivity.
8.
7. Plan to use the right or left radial pulse site
8. unless it is inaccessible or difficult to palpate.
Implementation
9. Introduce yourself to the client, if you have
not done so earlier.
11. Raise the height of the bed.

13. Help the client to a position of comfort.
14. Rest or support the client’s forearm with
the wrist extended.
15. Press the first and second fingertips
toward the radius while feeling for a
recurrent pulsation.
16. Palpate the rhythm and volume of the
pulse once it is located.
17. Note the position of the second hand on
the clock or watch.
18. Count the number of pulsations for 15 or
30 seconds and multiply the number by 4 or
2 respectively. If the pulse is irregular,
count for a full minute.
19. Write down the pulse rate.
20. Restore the client to a therapeutic position
or one that provides comfort, and lower
the bed.
21. Record assessed measurement on the
graphic sheet or the flow sheet or in
the narrative nursing notes.
22. Verbally report rapid or slow pulse rates.
Document
23. Date and time
24. Assessment site
25. Rate of pulsations per minute, pulse
volume, and rhythm
if appropriate
reported and outcome of the interaction
TOTAL

Student’s Name: Date:
Instructor/ Evaluator Name:

Satisfactory
NeedsPractice
Excellent
Skill 2-3: Assessing The Respiratory Rate

Goals: Respiratory rate is counted for an
appropriate time, respiratory rate is consistent
with the client’s condition. Comments
1 0.5 0
Assessment
monitor the client’s respiratory rate.
2. Review the data collected in previous
assessments of the respiratory rate and
other vital signs.
respiratory, cardiac, or neurologic disorders.
that may have respiratory or neurologic
effects.
Planning
5. Arrange to count the client’s respiratory rate
as close to the scheduled routine as possible.
6. Make sure a watch or wall clock with a
second hand is available.
7. Plan to assess the client’s respiratory rate
after a 5-minute period of inactivity.
Implementation
8. Introduce yourself to the client, if you have
not done so previously.

12. Help the client to a sitting or lying position.
13. Note the position of the second hand on
the clock or watch.
14. Choose a time when the client is unaware of
being watched; it may help to count the
respiratory rate while appearing to count
the pulse or while the client holds a
thermometer in the mouth.
15. Observe the rise and fall of the client’s
chest for a full minute, if breathing is
unusual. If breathing appears noiseless and
effortless, count ventilations for a fractional
portion of 1 minute and then multiply to
calculate the rate.
16. Write down the respiratory rate.
the bed.
18. Record assessed measurement on
the graphic sheet or flow sheet, or in
19. Verbally report rapid or slow respiratory
rates or any other unusual characteristics.
Document
20. Date and time
21. Rate per minute
if appropriate
TOTAL

Skill 2-4: Assessing Blood Pressure

NeedsPractice
Satisfactory
Excellent
Goals: Korotkoff sounds are heard clearly, blood

pressure is consistent with the client’s condition. Comments
1 0.5 0
Assessment
monitor the client’s blood pressure.
2. Review the data collected in previous
assessments.
3. Determine in which arm and in what position
previous assessments were made.
cardiac or vascular disorders.
that may have cardiovascular effects.
Planning
6. Gather the necessary supplies: blood
pressure cuff, sphygmomanometer, and
stethoscope.
7. Select an appropriately sized cuff for the
client.
8. Arrange to take the client’s blood pressure as
near to the scheduled routine as possible.
9. Plan to assess the blood pressure after at
least 5 minutes of inactivity unless it is an
emergency.
10. Wait 30 minutes after the client has
ingested caffeine or used tobacco.
11. Plan to use the right or left arm

unless inaccessible.
Implementation
12. Introduce yourself to the client, if you
have not done so earlier.
16. Help the client to a sitting position or one
of comfort.
17. Support the client’s forearm at the level of
the heart with palm of the hand upward.
18. Expose the inner aspect of the elbow by
removing clothing or loosely rolling up
a sleeve.
19. Center the cuff bladder so that the lower
edge is about 1 to 2 inches (2.5 to 5 cm)
above the inner aspect of the elbow.
20. Wrap the cuff snugly and uniformly
about the circumference of the arm.
21. Make sure the aneroid gauge can be
clearly seen.
22. Palpate the brachial pulse.
23. Tighten the screw valve on the bulb.
24. Compress the bulb until the pulsation
within the artery stops and note the
measurement at that point.
25. Deflate the cuff and wait 15 to 30 seconds.
26. Place the eartips of the stethoscope within
the ears and position the bell of the
stethoscope lightly over the location of the
brachial artery. The diaphragm may be
used, but it is not preferred.
27. Keep the tubing free from contact
with clothing.
28. Pump the cuff bladder to a pressure that is
30 mm Hg above the point where the
pulse previously disappeared.
29. Loosen the screw on the valve.
30. Control the release of air at a rate of

approximately 2 to 3 mm Hg per second.
31. Listen for the onset and changes in
Korotkoff sounds.
32. Read the manometer gauge to the closest
even number when phase I, IV, or V is noted.
33. Release the air quickly when there has
been silence for at least 10 mm Hg.
34. Write down the blood
pressure measurements.
35. Repeat the assessment after waiting at
least 1 minute if unsure of the pressure
measurements.
the bed.
38. Record assessed measurement on
the graphic sheet or flow sheet, or in
39. Verbally report elevated or low
blood pressure measurements.
Document
40. Date and time
41. Systolic and diastolic
pressure measurements
42. Assessment site
43. Position of the client
if appropriate
TOTAL

Skill 9-1: Monitoring with Pulse Oximetry

NeedsPractice
Excellent
Satisfactory
Goals: SpO2 measurements remain within 95% to

100%, client exhibits no evidence of hypoxemia or
hypoxia, SpO2 measurements correlate with
SaO2 measurements. Comments
1 0.5 0
Assessment
1. Identify indications for continuous or
intermittent oximetry monitoring.
2. Assess client's baseline respiratory status
including vital signs, skin and nailbed color,
breath sounds, dyspnea, alterations in
breathing patterns, current oxygen
supplementation, presence of dysrhythmias,
and tissue perfusion of extremities.
3. Review laboratory hemoglobin values to
identify anemic clients whose oxygen
content in the blood may be low although
their SaO2 is within normal levels.
4. To choose appropriate sensor, observe
client's height, weight, and size, and note
any allergies to adhesive.
Planning
5. Explain the procedure to the client
6. Obtain equipment
Implementation
7. Select appropriate type of sensor. A wide
variety of sensors are available in sizes for
neonates, infants, children, and adults. In
addition, there are clip-on, adhesive, and

disposable sensors. To select the appropriate
sensor, consider the client's weight, activity
level, if infection control is a concern, tape
allergies, and anticipated duration of
monitoring.
8. Instruct client to breathe normally.
9. Select appropriate site to place sensor.
Avoid using lower extremities that may have
compromised circulation, or extremities
receiving infusions or other invasive
monitoring. If client has poor tissue
perfusion due to peripheral vascular disease
or is receiving vasoconstrictor medications,
a nasal sensor or forehead sensor may be
considered.
10. Remove nail polish or acrylic nail from
digit to be used.
11. Attach sensor probe and connect it to the
pulse oximeter. Make sure the
photosensors are accurately aligned.
12. Watch for pulse-sensing bar on face of
oximeter to fluctuate with each
pulsation and reflect pulse strength.
Double-check machine pulsations with
client's radial or apical pulse
13. If continuous pulse oximetry is desired, set
the alarm limits on the monitor to reflect
the high and low oxygen saturation and
pulse rates. Ensure that the alarms are
audible before leaving the client. Inspect the
sensor site every 4 hours for tissue irritation
or pressure from the sensor.
14. Read saturation on monitor and document
as appropriate with all relevant information
on client's chart. Report SaO2 less than
93% to physician.
Document
15. Normal SpO2measurements once a
shift unless ordered otherwise
16. Abnormal SpO2measurements when
they are sustained
17. Nursing measures to improve oxygenation

if SpO2 levels fall below 90% and are
prolonged
18. Person to whom abnormal
measurements have been reported and
outcome of communication
19. Removal and relocation of sensor
20. Condition of skin at sensor site
TOTAL


NeedsPractice
Satisfactory
Skill 1-1: Performing Hand Hygiene Using Soap and Water

Excellent
Goal: Hand washing has met time requirements,

hands are clean, and skin is intact. Comments
1 0.5 0
Assessment
1. Review the medical record to determine if it is
appropriate to perform handwashing for
longer than 15 seconds.
2. Check that there are soap and paper towels
near the sink and a waste receptacle nearby.
Planning
3. Trim long fingernails so they are less than 1/4
inch long.
4. Remove all jewelry; a plain, smooth wedding
band can be worn; roll up long sleeves.
5. Explain the purpose for handwashing to the
client.
Implementation
6. Turn on the water using faucet handles;
automated faucet; or elbow, knee, or foot
controls.
7. If a lever-operated paper towel dispenser is
available, activate it to dispense the paper
towel.
8. Wet your hands with comfortably warm water
from the wrists toward the fingers.
9. Avoid splashing water from the sink onto your
uniform.
10. Dispense about 3 to 5 mL (1 tsp) of liquid soap

into your hands, or wet a cake of bar soap.
11. Work the soap into a lather and
generate friction.
12. Rinse the bar soap, if used, and replace
it within a drainable soap dish.
13. Rub the lather vigorously over all surfaces of
the hands including thumbs and backs of
fingers and hands and under the fingernails.
1. Right palm over left dorsum with
interlaced fingers and vice versa
2. Palm to palm with fingers interlaced
3. Backs of fingers to opposing palms
with fingers interlocked
4. Rotational rubbing of left thumb clasped
in right palm and vice versa.
5. Rinse the soap from your hands by letting the

water run from the wrists toward the fingers.
6. Stop the flow of water if it is controlled by an
elbow or knee lever, or a foot pedal.
7. Hold your draining hands lower than
your wrists.
8. Dry your hands thoroughly with paper towels
or similar item.
9. Turn the hand controls of the faucet off using a
paper towel.
10. Apply hand lotion from time to time.
Document
11. Because handwashing is performed so
frequently, it is not documented, but it is
expected as a standard for care among
all health care personnel.
TOTAL

Skill 1-2: Performing Hand Hygiene Using an Alcohol –

NeedsPractice
Satisfactory
Based Hand Rub

Excellent
Goal: Transient microorganisms are eliminated

from the hands. Comments
1 0.5 0
Assessment
1. Review the medical record to determine if it is
appropriate to perform hand hygiene for longer
than 20 seconds
Planning
2. Trim long fingernails so they are less than 1/4
inch long.
3. Remove all jewelry; a plain, smooth wedding
band can be worn; roll up long sleeves.
4. Explain the purpose for hand hygiene to the
client.
Implementation
5. Remove jewelry, if possible, and secure in a safe
place. A plain wedding band may remain in
place.
6. Check the product labeling for correct amount
of product needed.
7. Apply the correct amount of product to the
a. Palm in a cupped hand, covering all surfaces.
b. Rub hands palm to palm
c. Right palm over left dorsum with interlaced
fingers and vice versa;
d. Palm to palm with fingers interlaced;
e. Backs of fingers to opposing palms with

fingers interlocked;
f. Rotational rubbing of left thumb clasped in
right palm and vice versa;
g. Rotational rubbing, backwards and forwards
with clasped fingers of right had in left palm
and vice versa;
h. Once dry; your hands are safe.
8. Rub hands together until they are dry (at 20 - 30
seconds).
9. Use oil-free lotion on hands if desired.
Documentation
10. Because hand hygiene is performed so
frequently, it is not documented, but it is
expected as a standard for care among all
health care personnel.
TOTAL

NeedsPractice
Skill 1-4: Applying and Removing Personal Protective
Satisfactory
Excellen
Equipment (Gloves, Gown, Mask, Eyewear)

Goals: Ensure that the healthcare workers and
t
clients free from transmission of potential

infective materials. Comments
1 0.5 0
Assessment
1. Consider which activities will be required
while the nurse is in the client’s room at this
time.
Planning
2. Application and removal of PPE can be time
consuming. Prioritize care and arrange for
personnel to care for your other clients if
indicated.
3. Determine which supplies are present within
the client’s room
4.and which must be brought to the room
5. Consider if special handling is indicated for
removal of any specimens or other materials
from the room.
Implementation
6. Remove or secure all loose items such as
name tags or jewelry.
7. Prior to performing the procedure, introduce
self and verify the client’s identity using
agency protocol. Explain to the client what
you are going to do, why it is necessary, and
how he or she can participate.
8. Perform hand hygiene

9. Apply a clean gown.
a. Pick up a clean gown, and allow it to
unfold in front of you without allowing
it to touch any area soiled with body
substances.
b. Slide the arms and the hands through
the sleeves.
c. Fasten the ties at the neck to keep the
gown in place.
d. Overlap the gown at the back as much as
possible, and fasten the waist ties or belt
10. Apply the face mask.
a. Locate the top edge of the mask. The
mask usually has a narrow metal
strip along the edge.
b. Hold the mask by the top two strings or
loops.
c. Place the upper edge of the mask over
the bridge of the nose, and tie the upper
ties at the back of the head or secure the
loops around the ears. If glasses are worn,
fit the upper edge of the mask under the
glasses.
d. Secure the lower edge of the mask under
the chin, and tie the lower ties at the
nape of the neck.
e. If the mask has a metal strip, adjust
this firmly over the bridge of the nose
f. Wear the mask only once, and do not
wear any mask longer than the
manufacturer recommends or once it
becomes wet
g. Do not leave a used face mask hanging
around the neck. The Practice Guidelines
provide further instructions on applying
a face mask.
11. Apply protective eyewear if it is
not combined with the face mask.
12. Apply clean gloves.
a. No special technique is required.
b. If wearing a gown, pull the gloves up to
cover the cuffs of the gown. If not wearing
a gown, pull the gloves up to cover the

wrists.
13. To remove soiled PPE, remove the gloves
first since they are the most soiled.
a. If wearing a gown that is tied at the
waist in front, undo the ties before
removing gloves.
b. Remove the first glove by grasping it on
its palmar surface, taking care to touch
only glove to glove
c. Pull the first glove completely off by
inverting or rolling the glove inside out.
d. Continue to hold the inverted removed
glove by the fingers of the remaining
gloved hand. Place the first two fingers
of the bare hand inside the cuff of the
second glove.
e. Pull the second glove off to the fingers
by turning it inside out. This pulls the
first glove inside the second glove.
f. Using the bare hand, continue to remove
the gloves, which are now inside out, and
dispose of them in the refuse container.
14. Perform hand hygiene.
15. Remove protective eyewear and dispose
of properly or place in the appropriate
receptacle for cleaning.
16. Remove the gown when preparing to
leave the room.
a. Avoid touching soiled parts on the outside
of the gown, if possible.
b. Grasp the gown along the inside of the
neck and pull down over the shoulders.
Do not shake the gown.
c. Roll up the gown with the soiled part
inside, and discard it in the
appropriate container.
17. Remove the mask.
a. Remove the mask at the doorway to
the client’s room. If using a respirator
mask, remove it after leaving the room
and closing the door.
b. If using a mask with strings, first untie

the lower strings of the mask
c. Untie the top strings and, while holding the
ties securely, remove the mask from the
face. If side loops are present, lift the side
loops up and away from the ears and face.
Do not touch the front of the mask
d. Discard a disposable mask in the waste
container.
e. Perform proper hand hygiene again.
TOTAL


Satisfactory
Skill 6-1: Giving a Bed Bath

NeedsPractice
Excellent
Goals: Client is completely bathed, client

experiences no discomfort or intolerance of
activity. Comments
1 0.5 0
Assessment
1. Check the Kardex or nursing care plan for
hygiene directives.
2. Inspect the skin for signs of dryness,
drainage, or secretions.
Planning
3. Consult with the client to determine a
convenient time for tending to hygiene
needs.
4. Assemble supplies: bath blanket, towels,
face cloths, soap, wash basin, clean
pajamas or gown, clean bed linen, other
hygiene articles such as deodorant or
antiperspirant, and a razor for males.
Implementation
6. Pull the privacy curtain.
7. Raise the bed to an appropriate height.
8. Remove extra pillows or positioning
devices and place the client on his or her
back.
9. Cover the client with a bath blanket.
29
10. Remove the client’s gown.

11. While the client holds the top of the bath
blanket, pull and fan-fold the top linen to
the bottom of the bed, or remove the
linen, fold it, and lay it on a chair.
12. If linen is too soiled for reuse, place it in
a laundry hamper.
13. Hold dirty linen away from contact
with your uniform.
14. Fill a basin with 105 to 110 F (40 to
43 C) water; place the basin on the
overbed table.
15. Wet the washcloth and fold it to fashion
a mitt.
16. Wipe each eye with a separate corner of
the mitt from the nose toward the ear.
17. Lather the wet washcloth with soap
and finish washing the face.
18. Rinse the washcloth and remove soapy
residue from the face, then dry well.
19. Bathe each of the client’s arms
separately; the axillae may be included
now or when the chest is washed.
20. Offer to apply deodorant or
antiperspirant after washing the axillae.
21. Place each hand in the basin of water
as you wash it.
22. Discard and replace the water in the
basin; rinse the washcloth well or replace
it with a clean one.
23. Wash the chest, abdomen, each leg,
then the feet following the steps
described for the upper body.
24. Help the client onto his or her side.
25. Change the water and bathe the
client’s back.
26. Offer to apply lotion and provide a
back rub.
27. Don gloves and wash the buttocks,
genitals, and anus last. Dry thoroughly.
28. Discard the water and wipe the basin dry.
29. Remove gloves and help the client to don

a fresh gown.
Document
30. Date and time
31. Type and extent of hygiene
32. Client response
33. Assessment findings observed during bath
TOTAL


Satisfactory
NeedsPractice
Skill 6-2: Giving Oral Care to Unconscious Clients
Excellent
Goals: The teeth are clean, the oral mucosa is

smooth, pink, moist, and intact, safety is
maintained. Comments
1 0.5 0
Assessment
1. Check the nursing care plan about the
frequency of oral hygiene.
2. Inspect the client’s mouth.
3. Look for oral hygiene supplies that may be at
the client’s bedside already.
Planning
4. Arrange to brush the client’s teeth once per
shift and to provide additional oral care at
least every 2 hours if necessary.
5. Assemble the following equipment:
toothbrush, toothpaste, suction catheter,
water, bulb syringe, padded tongue blade,
emesis basin, towel or absorbent pad, and
gloves. Some agencies may stock a
toothbrushing device connected directly to a
suction catheter.
Implementation
6. Explain to the client what you are about to
do.
7. Position the client on the side with the head
slightly lowered.
8. Place a towel beneath the head.
32
9. Connect a Yankeur suction tip or catheter to a

portable or wall-mounted suction source.
10. Spread toothpaste over a
moistened toothbrush.
11. Don gloves.
12. Use a tongue blade or lower the client’s chin
to open the mouth and separate the teeth.
13. Brush all tooth surfaces with the toothbrush.
14. Instill water and suction the mouth with
a bulb syringe or Yankeur suction device.
15. Clean and store oral hygiene supplies.
16. Remove wet towel and gloves; restore
client to a position of comfort and safety.
Document
17. Date and time
18. Assessment findings if significant
19. Type of oral care
20. Unusual events such as choking and
nursing action that was taken
21. Outcome of any nursing action
TOTAL


Satisfactory
NeedsPractice
Skill 4-1: Making An Unoccupied Bed

Excellent
Goals: The bed is clean and dry, the linen is free

of wrinkles, the environment is orderly, the client
feels comfortable Comments
1 0.5 0
Assessment
1. Check the Kardex or nursing care plan to
determine the client’s activity level.
2. Inspect the linen for moisture or evidence of
soiling.
Planning
3. Plan to change the linen after the client’s
hygiene needs have been met.
4. Wash hands or perform hand antisepsis with
an alcohol rub. Use gloves if there is a
potential for direct contact with blood, stool,
or other body fluids.
5. Bring necessary bed linen to the room.
6. Place the clean linen on a clean, dry surface
such as the seat or back of a chair.
7. Assist the client from the bed.
Implementation
8. Raise the bed to a high position and lower
siderails.
9. Remove equipment attached to the bed
linens, such as the signal cord and drainage
tubes, and check for personal items.
34
10. Loosen the bed linen from where it has

been tucked under the mattress.
11. Fold any linen that may be reused and
place it on a clean surface.
12. Don gloves, if necessary, and roll linen that
will be replaced so that the soiled surface
is enclosed.
13. Remove the soiled linen while holding
it away from your uniform.
14. Place the soiled linen directly into a
pillowcase, laundry hamper, or self-made
pouch from one of the removed sheets.
Do not place the soiled linen on the floor.
15. Remove gloves and wash hands or
perform hand antisepsis with an alcohol
rub once contact with body secretions is
no longer likely.
16. Reposition the mattress so it is flush with
the headboard.
17. Tighten any linen that will be reused.
18. If the bottom sheet needs changing, center
the longitudinal fold and open the layers of
folded linen to one side of the bed.
19. If using a flat sheet, make sure the flat
edge of the hem is flush with the edge of
the mattress at the foot end.
20. If using a flat sheet, tuck the upper portion
under the mattress. Make a mitered or
square corner at the top of the bed.
21. If using a fitted sheet, position the upper
and lower corners of the mattress within the
contoured corners of the sheet.
22. If the client is apt to soil the linen with urine
or stool, fold a flat sheet horizontally with
the smooth edge of the hem toward the
foot of the bed and tuck it in place
approximately where the buttocks will be.
Do the same if a draw sheet is available.
23. Position the top linen on one half of the
bed at this time. Move to the other side of
the bed, pull the linen taut, and tuck the
free edges beneath the mattress.
35
24. Alternatively wait until you have secured all

the bottom linen to position the top sheet.
25. Center the top sheet and unfold it to one
side, leaving sufficient length at the top
to make a fold over the spread.
26. Add blankets if the client wishes.
27. Cover the top sheet with the spread if
desired. Tuck the excess linen at the foot of
the bed under the bottom of the mattress
and finish the sides with a mitered or
square corner.
28. Smooth the top sheet
29. Gather the pillowcase as you would
hosiery and slip the case over the pillow.
30. Place the pillow at the head of the bed
with the open end away from the door and
the seam of the pillowcase toward the
headboard.
31. Fan-fold or pie-fold the top linen toward
the foot of the bed.
32. Secure the signal device on or to the bed.
33. Adjust the bed to a low position.
Document
35. Date and time
36. Characteristics of drainage if present
37. Any unique measures taken to ensure
client comfort
TOTAL


Satisfactory
Skill 4-2: Making an Occupied Bed

NeedsPractice
Excellent
Goals: The bed is clean and dry, the linen is free

of wrinkles, the environment is orderly, the client
feels comfortable Comments
1 0.5 0
Assessment
1. Check the Kardex or nursing care plan to
confirm that the client must remain in bed.
2. Assess the client’s level of consciousness,
physical strength, breathing pattern, heart
rate, and blood pressure.
3. Inspect the linen for moisture or evidence of
soiling.
4. Determine who might be available to assist if
the client is too weak or unable to
cooperate.
Planning
5. Plan to change the linen after the client’s
hygiene needs have been met.
6. Wash hands or perform hand antisepsis with
an alcohol rub. Use gloves if there is a
potential for direct contact with blood, stool,
or other body fluids.
7. Bring necessary bed linen to the room.
8. Place the clean linen on a clean, dry surface
such as the back of a chair.
Implementation
9. Explain what you plan to do.
10. Raise the bed to a high position.

11. Cover the client with a bath blanket or leave
the top sheet loosened but in place.
12. Fold the top sheet or spread if it will be
reused and place it on a clean surface.
13. Unfasten equipment attached to the
bottom linen and check for personal items.
14. Loosen the bed linen from where it has
been tucked under the mattress.
15. Lower the rail on the side of the bed
where you are standing and roll the client
toward the opposite side rail.
16. Roll the soiled bottom sheets as close to
the client as possible.
17. Proceed to unfold and tuck the bottom
sheet and drawsheet on the vacant side of
the bed, as described in Skill 18-1.
18. Fold the free edges of the sheet under
the folded portion of the soiled sheets.
19. Raise the siderail and move to the
opposite side of the bed.
20. Lower the siderail in your new position
and help the client to roll over the mound
of sheets.
21. Pull the soiled laundry close to the edge of
the bed and the clean linen close beside it.
22. Remove the soiled linen and place it into
a pillowcase or pouch that is off the floor.
23. Pull the clean bottom sheet until it
is unfolded from beneath the client.
24. Miter or square the upper corner of the
sheet; pull and tuck the free edges under
the mattress.
25. Assist the client to the middle of the bed.
26. Straighten or replace the top sheet,
blankets, and spread; remove and replace
the pillowcase if necessary.
27. Reposition the client according to
the therapeutic regimen or comfort.
28. Lower the height of the bed and raise
the remaining siderail if appropriate.
29. Dispose of the soiled linen in a

laundry hamper outside the room.
Document
31. Date and time
32. Characteristics of drainage if present
33. Measures taken to ensure client comfort.
TOTAL

NeedsPractice
Skill 8-1:Administering Oral Medications

Excel
Satisfactory
lent
Goals: The five rights are upheld, client experiences no

choking or aspiration, client exhibits a therapeutic
response to the medication, client demonstrates minimal

or absent side effects. Comments
1 0.5 0
Assessment
1. Compare the medication administration record (MAR)
with the written medical order.
2. Review the client’s drug, allergy, and medical history.
3. Consult a current drug reference concerning the
drug’s action, side effects, contraindications, and
administration information.
Planning
4. Plan to administer medications within 30 to 60
minutes of their scheduled time.
5. Allow sufficient time to prepare the medications in a
location with minimal distractions.
6. Make sure that there is a sufficient supply of paper
and plastic medication cups.
7. Chill oily medications.
Implementation
8. Wash your hands or perform an alcohol-based
handrub.
9. Read and compare the label on the drug with the
MAR at least three times—before, during, and after
preparing the drug.
10. Calculate doses.
11. Place medications or unit dose packets within a paper
or plastic cup without touching the medication itself.

12. Keep drugs that require special assessments or
administration techniques in a separate cup.
13. Pour liquids with drug label toward the palm of hand.
14. Hold the cup for liquid medications at eye level when
pouring.
15. Prepare a supply of soft-textured food such as
applesauce or pudding, according to the client’s
individual needs.
16. Help the client to a sitting position.
17. Identify the client by checking the wristband or asking
the client’s name.
18. Offer a cup of water with solid forms of oral
medications.
19. Advice the client to take medications one at a time or
in amounts easily swallowed.
20. Encourage the client to keep his or her head in a
neutral position or one of slight flexion, rather than
hyperextending the neck.
21. Remain with the client until he or she has swallowed
the medications.
22. Restore the client to a position of comfort and safety.
23. Record the volume of fluid consumed on the intake
and output record.
24. Record the administration of the medication.
25. Assess the client in 30 minutes for desired and
undesired drug effects.
Document
26. Preassessment data if indicated
27. Date, time, drug, dose, route, signature, title, and
initials (usually on the MAR)
28. Evidence of client’s response if it can be determined
TOTAL


Satisfactory
NeedsPractice
Skill 8-2: Instilling Eye Medications
Excellent
Goals: The five rights are upheld, the tip of the

container remains uncontaminated, sufficient drug is
distributed within the eye. Comments
1 0.5 0
Assessment
1. Compare the medication administration record
(MAR) with the written medical order.
2. Review the client’s drug, allergy, and medical
history.
Planning
5. Allow sufficient time to prepare medications in a
6. Warm eye drops and ointments by holding them
between the hands if they have not been stored
at room temperature.
MAR at least three times—before, during, and
after preparing the drug.
Implementation
handrub.
9. Identify the client by checking the wristband or
asking the client’s name.
10. Position the client supine or sitting with the

head tilted back and slightly to the side into
which the medication will be instilled.
11. Don clean gloves.
12. Clean the lids and lashes if they contain debris. Use
a cotton ball or tissue moistened with water.
13. Wipe the eye from the corner by the nose,
called the inner canthus, toward the corner near
the temple, called the outer canthus.
14. Instruct the client to look toward the ceiling.
15. Make a pouch in the lower lid by pulling the
skin downward over the bony orbit.
16. Move the container of medication from below
the client’s line of vision or from the side of
the eye.
17. Steady the container above the location for
instillation without touching the eye surface.
18. Instill the prescribed number of drops into the
appropriate eye within the conjunctival pouch.
19. If using ointment, squeeze a ribbon onto
the lower lid margin.
20. Instruct the client to close the eyelids gently
then blink several times.
21. Wipe the eyes with a clean tissue.
Document
22. Assessment data
23. Medication administration on the MAR
TOTAL


Satisfactory
NeedsPractice
Skill 8-3: Administering Nasal Medications
Excellent
Goals: The five rights are upheld, sufficient drug is

distributed within the nose, and client reports
decreased nasal congestion. Comments
1 0.5 0
Assessment
2. Review the client’s drug, allergy, and medical
history.
Planning
5. Allow sufficient time to prepare the medications
in a location with minimal distractions.
Implementation
handrub.
8. Identify the client by checking the wristband or
asking the client’s name.
9. Help the client to a sitting or lying position with
his or her head tilted backward or to the side if
the drug needs to reach one or the other
sinuses.
10. Place a rolled towel or pillow beneath the neck
if the client cannot sit.
11. Remove the cap from liquid medication to
which a dropper usually is attached.
12. Aim the tip of the dropper toward the nasal
passage and squeeze the rubber portion of
the cap to administer the number of drops
prescribed.
13. Instruct the client to breathe through the
mouth as the drops are instilled.
14. If the drug is in a spray form, place the tip of
the container just inside the nostril.
15. Occlude the opposite nostril.
16. Instruct the client to inhale as the container
is squeezed.
17. Repeat in the opposite nostril.
18. Advise the client to remain in position
for approximately 5 minutes.
19. Recap the container and replace
where medications are stored.
Document
20. Assessment data
TOTAL

Needs Practice
Skill 8-4: Instilling Ear Drops
Satisfactory
Excellent
Goals: Drops administered successfully. Comments

1 0.5 0
Assessment
1. Appearance of the pinna of the ear and
meatus for signs of redness and abrasions
2. Type and amount of any discharge.
Planning
3. Check the MAR.
a. Check the MAR for the drug
name, strength, number of drops,
and prescribed frequency.
b. Check client allergy status.
c. If the MAR is unclear or pertinent
information is missing, compare it with
the most recent primary care
provider’s written order.
d. Report any discrepancies to the charge
nurse or primary care provider, as
agency policy dictates.
4. Know the reason why the client is receiving
the medication, the drug classification,
contraindications, usual dose range, side
effects, and nursing considerations for
administering and evaluating the intended
outcomes of the medication.
Implementation
5. Compare the label on the medication

container with the medication record and
check the expiration date. If necessary,
calculate the medication dosage.
6. Explain to the client what you are going to

do, why it is necessary, and how he or she
can participate. The administration of an
otic medication is not usually painful.
Discuss how the results will be used in
planning further care or treatments.
7. Perform hand hygiene and observe other
appropriate infection prevention procedures.
8. Provide for client privacy.
9. Prepare the client.
a. Prior to performing the procedure,
introduce self and verify the client’s
identity using agency protocol.
b. Assist the client to a comfortable
position for eardrop administration, lying
with the ear being treated uppermost.
10. Clean the pinna of the ear and the meatus
of the ear canal.
a. Apply gloves if infection is suspected.
b. Use cotton-tipped applicators and
solution to wipe the pinna and auditory
meatus. Ensure that applicator does
not go into the ear canal.
11. Administer the ear medication.
a. Warm the medication container in your
hand, or place it in warm water for a
short time.
b. Partially fill the ear dropper
with medication.
c. Straighten the auditory canal. Pull the
pinna upward and backward for clients
over 3 years of age.
d. Instill the correct number of drops along
the side of the ear canal
e. Press gently but firmly a few times on the
tragus of the ear (the cartilaginous
projection in front of the exterior meatus of
the ear).
f. Ask the client to remain in the side-lying

position for about 5 minutes.
g. Insert a small piece of cotton fluff loosely at
the meatus of the auditory canal for 15 to 20
minutes. Do not press it into the canal
12. Remove and discard gloves.
a. Perform hand hygiene.
Document
13. Document the administration of
the medication immediately after
administration.
TOTAL

NeedsPractice
Satisfactory
Skill 8-5: Administering Intradermal Injections

Excellent
Goals: Injection is administered, client remains free

of any untoward effects. Comments
1 0.5 0
Assessment
1. Check the medical orders.
4. Check for any documented allergies to food or
drugs.
5. Determine how much the client understands
about the purpose and technique for
administering the injection.
Planning
6. Prepare to administer the injection according to
the schedule prescribed.
7. Obtain clean gloves, tuberculin syringe,
appropriate needle, and alcohol swabs.
8. Prepare the syringe with the medication.
Implementation
handrub; don gloves.
10. Read the name on the client’s identification
band.
12. Select an area on the inner aspect of the

forearm, approximately a hand’s breadth
above the client’s wrist.
13. Cleanse the area with an alcohol swab using a
circular motion outward from the site where
the needle will pierce the skin.
14. Allow the skin to dry.
15. Hold the client’s arm and stretch the skin taut.
16. Hold the syringe almost parallel to the skin at a
10- to 15-degree angle with the bevel pointing
upward.* Then insert the needle about 1/8 inch.
17. Push the plunger of the syringe and watch for
a small wheal (elevated circle) to appear.
18. Withdraw the needle at the same angle at
which it was inserted.
19. Do not massage the area after removing
the needle.
20. Deposit the uncapped needle and syringe in
a puncture-resistant container.
21. Remove gloves and perform hand hygiene.
22. Observe the client’s condition for at least the first
30 minutes after performing an allergy test.
23. Observe the area for signs of a local reaction at
standard intervals such as 24 and 48 hours
after the injection.
Document
24. The date, time, drug, dose, route, and
specific site
25. Client response
TOTAL

*
NeedsPractice
Satisfactory
Skill 8-6: Administering Subcutaneous Injections

Excellent
Goals: Injection is administered, client experiences

no untoward effects. Comments
1 0.5 0
Assessment
4. Check for any documented allergies to food or
drugs.
5. Determine where the last injection was given to
ensure site rotation.
7. Inspect the potential injection site for signs of
bruising, swelling, redness, warmth, or
tenderness.
Planning
9. Obtain clean gloves, appropriate syringe and
needle, and alcohol swabs.
11. Add 0.1 to 0.2 mL of air to the syringe.
Implementation
12. Wash your hands or perform an alcohol-
based handrub; don gloves.
13. Read the name on the client’s
identification band.
15. Select and prepare an appropriate site
by cleansing it with an alcohol swab.
17. Bunch the skin.
18. Pierce the skin at a 45-degree or 90-degree
angle of entry.
19. Release the tissue once the needle is inserted;
use the hand to support the syringe at its hub.
20. Do not aspirate.
21. Inject the medication 5 seconds after the needle
has been embedded within the tissue by
pushing on the plunger.
22. Withdraw the needle quickly while applying
pressure against the medication site.
23. Massage the site, unless contraindicated.
25. Remove gloves; perform hand hygiene.
26. Assess the client’s condition at least 30
minutes after giving the injection.
Document
specific site
28. Site assessment data
29. Client’s response
TOTAL

NeedsPractice
Satisfactory
Skill 8-7: Administering Intramuscular Injections

Excellent
Goals: Injection is administered, client experiences

no untoward effects. Comments
1 0.5 0
Assessment
4. Check for any documented drug allergies.
5. Determine where the last injection was given.
7. Inspect the potential injection site for signs of
bruising, swelling, redness, warmth, tenderness,
or induration (hardness).
Planning
9. Obtain clean gloves, appropriate syringe and
needle, and alcohol swabs.
11. Add 0.2 mL of air to the syringe.
Implementation
based handrub; don gloves.
13. Read the name on the client’s
identification band.
15. Select and prepare an appropriate site
by cleansing it with an alcohol swab.
17. Spread the tissue taut.
18. Hold the syringe like a dart and pierce the skin
at a 90-degree angle.
19. Steady the syringe and aspirate to observe
for blood.
20. Instill the drug if no blood is apparent.
21. Withdraw the needle quickly at the same angle
it was inserted while applying pressure against
the site.
22. Massage the injection site with the alcohol
swab unless contraindicated.
24. Remove gloves; perform hand hygiene.
25. Assess the client’s condition at least 30
minutes after giving the injection.
Document
specific site
27. Site assessment data
TOTAL

NeedsPractice
Skill 8-8: Administering A Rectal Suppository
Satisfactory
Excellent
Goals: Client retains suppository for 15 minutes,

bowel elimination occurs. Comments
1 0.5 0
Assessment
2. Compare the medication administration
record (MAR) with the written medical
order.
3. Read and compare the label on the
suppository with the MAR at least three
times—before, during, and after preparing
the drug.
4. Determine how much the client
understands the purpose and technique for
administering a suppository.
Planning
5. Prepare to administer the suppository
according to the time prescribed by the
physician.
6. Obtain clean gloves and lubricant.
Implementation
based handrub.
8. Read the name on the client’s identification
band.
10. Place the client in a Sims’ position.

11. Drape the client to expose only the
buttocks.
12. Don gloves.
13. Lubricate the suppository and index finger
of the dominant hand and separate the
buttocks so that the anus is in plain view.
14. Instruct the client to take several slow, deep
breaths. Introduce the suppository, tapered
end first, beyond the internal sphincter,
about the distance of the finger.
15. Avoid placing the suppository within stool.
16. Wipe excess lubricant from around
the anus with a paper tissue.
17. Tell the client to try to retain the
suppository for at least 15 minutes.
18. Suggest contracting the gluteal muscles
if there is a premature urge to expel the
suppository.
19. Ask the client to wait to flush the toilet
until the stool has been inspected.
20. Remove your gloves and wash your hands.
Document
21. Drug, dose, route, and time
22. Outcome of drug administration
TOTAL

Skill 8-9: Initiating a Peripheral Venous Access IV Infusion

NeedsPractice
Excellent
Satisfactory
Goals: A flashback of blood was observed before

advancing the catheter, minimal discomfort and blood
loss occurred, fluid is infusing at the prescribed rate. Comments
1 0.5 0
Assessment
1. Check the identity of the client.
2. Review the client’s medical record to determine if

there are any allergies to iodine or tape.
3. Inspect and palpate several potential venipuncture
sites.
Planning
4. Bring all the necessary equipment to the bedside.
5. Position the client on his or her back or in a sitting

position.
6. Place an absorbent pad beneath the hand or arm.
7. Select a site most likely to facilitate the purpose for

the infusion and comply with the criteria for vein
selection.
8. Clip body hair at the site if it is excessive.
9. Apply topical anesthetic cream.
10. Tear strips of tape, open the package with the

venipuncture device, and place antiseptic ointment
on an opened Band-Aid or gauze square, based on
the agency’s policy.
Implementation
11. Wash hands or perform hand antisepsis with an

alcohol rub.
12. Apply a tourniquet or a blood pressure cuff 2 to 4
inches (5 to 10 cm) above the vein that will be used.
13. Use an antimicrobial solution such as Betadine
and/or alcohol to cleanse the skin, starting at the
center of the site outward 2 to 4 inches.
14. Allow the antiseptic to dry.
16. Use the thumb to stretch and stabilize the vein and
soft tissues about 2 inches (5 cm) below the
intended site of entry.
17. Position the venipuncture device with the bevel up
and at approximately a 45-degree angle above or to
the side of the vein.
18. Warn the client just before inserting the needle.
19. Feel for a change in resistance and look for blood to

appear behind the needle.
20. Once blood is observed, advance the needle about
1/8 inch to 1/4 inch.
21. Withdraw the needle slightly so that the tip is within
the catheter.
22. Slide the catheter into the vein until only the end of
the infusion device can be seen.
23. Release the tourniquet.
24. Apply pressure over the internal tip of the catheter.
25. Remove the protective cap covering the end of the

IV tubing and insert it into the end of the
venipuncture device.
26. Release the roller clamp and begin infusing solution
slowly.
27. Remove gloves when there is no longer a
potential for direct contact with blood.
28. Place a small amount of antiseptic ointment onto
the site or dressing.
29. Secure the catheter by crisscrossing a piece of tape
from beneath the tubing. Cover with a piece of
transparent tape.
58
30. Cover the entire site with additional strips of tape,

taking care to loop and secure the tubing.
31. Write the date, time, gauge of the catheter, and
your initials on the outer piece of tape.
32. Tighten or release the roller clamp to regulate the
rate of fluid infusion.
Document
33. Date and time
34. Gauge and type of venipuncture device
35. Site of venipuncture
36. Type and volume of solution
37. Rate of infusion
TOTAL
Evaluator’s Signature Student’s Signature

Skill 7-1: Collecting an Urine Specimen (Clean Catch,

NeedsPractice
Satisfactory
Midstream) for Urinalysis and Culture

Excellent
Goals: An adequate amount of urine is obtained

from the patient without contamination. Comments
1 0.5 0
Assessment
1. After verifying the physician’s order for
specimen collection, ask the patient about
any medications that he or she is taking,
because medications may affect the results
of the test
2. Assess for any signs and symptoms of a
urinary tract infection, such as burning,
pain (dysuria), or frequency.
3. Assess the patient’s ability to cooperate
with the collection process.
Planning
4. Bring necessary equipment to the bedside
stand or overbed table.
5. Identify the patient. Explain the procedure
to the patient. If the patient can perform
the task without assistance after
instruction, leave the container at bedside
with instructions to call the nurse as soon
as a specimen is produced.
Implementation
6. Perform hand hygiene and put on PPE, if
indicated.
7. Have the patient perform hand hygiene, if

performing self-collection
8. Check the specimen label with the patient’s
identification bracelet. Label should include
patient’s name and identification number,
time specimen was collected, route of
collection, identification of the person
obtaining sample, and any other information
required by agency policy.
9. Close curtains around bed and close
the door to the room, if possible.
10. Put on unsterile gloves. Assist the patient
to the bathroom, or onto the bedside
commode or bedpan. Instruct the patient
not to defecate or discard toilet paper
into the urine.
11. Instruct the female patient to separate the
labia for cleaning of the area and during
collection of urine. Female patients should
use the towelettes or wet washcloth to
clean each side of the urinary meatus,
then the center over the meatus, from
front to back, using a new wipe or a clean
area of the washcloth for each stroke.
Male patients should use a towelette to
clean the tip of the penis, wiping in a
circular motion away from the urethra.
Instruct the uncircumcised male patient to
retract the foreskin before cleaning and
during collection.
12. Have patient void a small amount of urine
into the toilet, bedpan, or commode. The
patient should then stop urinating briefly,
then void into collection container. Collect
specimen (10 to 20 mL is sufficient), and
then finish voiding. Do not touch the inside
of the container or the lid.
13. Place lid on container. If necessary, transfer
the specimen to appropriate containers for
ordered test, according to facility policy.
14. Assist the patient from the bathroom, off
the commode, or off the bedpan.
Provide perineal care, if necessary.

16. Place label on the container per facility
policy. Place container in plastic,
sealable biohazard bag.
17. Remove the other PPE, if used.
Perform hand hygiene.
18. Transport the specimen to the
laboratory as soon as possible. If unable
to take the specimen to the laboratory
immediately, refrigerate it.
Document
19. Document that the specimen was sent to
the laboratory. Note the characteristics
of the urine, including odor, amount (if
known), color, and clarity. Include any
significant patient assessments, such as
patient complaints of burning or pain on
urination.
TOTAL

Needs Practice
Skill 7-2: Collecting a Stool Specimen for Culture
Satisfactory
Excellent
Goals: An uncontaminated specimen is obtained

and sent to the laboratory promptly. Comments
1 0.5 0
Assessment
1. Assess the patient’s understanding of the
need for the test and the requirements
of the test
2. Assess the patient’s understanding of
the collection procedure and ability to
cooperate.
3. Ask the patient when his or her last bowel
movement was, and check the patient’s
medical record for this information.
Planning
4. Gather necessary equipment and bring
to the bedside.
5. Identify the patient. Discuss with the patient
the need for a stool sample. Explain to the
patient the process by which the stool will
be collected, either from a bedpan,
commode, or plastic receptacle in the toilet
to catch stool without urine. Instruct the
patient to void first and not to discard toilet
paper with stool. Tell the patient to call you
as soon as a bowel movement is completed.
6. Check specimen label with the patient’s
identification bracelet. Label should include
patient’s name and identification number,
time specimen was collected, route of

collection, identification of the person
obtaining the sample, and any other
information required by agency policy.
Implementation
7. Perform hand hygiene and put on PPE,
if indicated.
8. After the patient has passed a stool, put on
gloves. Use the tongue blades to obtain a
sample, free of blood or urine, and place it
in the designated clean container.
9. Collect as much of the stool as possible
to send to the laboratory.
10. Place lid on container. Dispose of used
equipment per facility policy. Remove
gloves and perform hand hygiene.
11. Place label on the container per facility
policy. Place container in plastic,
sealable biohazard bag.
12. Remove other PPE, if used. Perform
hand hygiene.
13. Transport the specimen to the laboratory
while stool is still warm. If immediate
transport is impossible, check with
laboratory personnel or policy manual
whether refrigeration is contraindicated.
Document
14. Document amount, color, and consistency
of stool obtained, time of collection, specific
test for which the specimen was collected,
and transport to laboratory.
TOTAL

Skill 9-1: Administering Oxygen by Nasal Cannula

Needs Practice
Satisfactory
Excellent
Goals: To deliver low to moderate levels of

oxygen to relieve hypoxia. Comments
1 0.5 0
Assessment
1. Assess respiratory status (i.e.,
breath sounds, respiratory rate and
depth, presence of sputum, arterial
blood gases if available).
2. Assess past medical history, noting
chronic obstructive pulmonary disease
(COPD). For clients with COPD,
hypoxemia is often the stimulus to
breathe because they chronically have
high blood levels of carbon dioxide. If
additional oxygen is needed, a low-flow
system is essential to maintain slight
hypoxemia so breathing is stimulated.
3. Assess for clinical signs and symptoms of
hypoxia: anxiety, decreased level of
consciousness, inability to concentrate,
fatigue, dizziness, cardiac dysrhythmias,
pallor or cyanosis, dyspnea.
Planning
4. Review chart for physician's order for
oxygen to ensure that it includes
method of delivery, flow rate,
titration orders; identify client.
5. Identify client and proceed with 5 rights

of medication administration. Explain
procedure to client. Explain that oxygen
will ease dyspnea or discomfort, and
inform client concerning safety
precautions associated with oxygen
use. Encourage him or her to breathe
through the nose.
6. “Crack” the portable oxygen tank if that
is the type of oxygen source being used.
7. Eliminate safety hazards that
may support a fire or explosion.
Implementation
8. Wash your hands.
9. Assist client to semi- or high
Fowler's position, if tolerated.
10. Insert flowmeter into wall outlet. Attach
oxygen tubing to nozzle on flowmeter. If
using a high O2 flow, attach humidifier.
Attach oxygen tubing to humidifier
11. Turn on the oxygen at the
prescribed rate. Check that oxygen is
flowing through tubing
12. Hold nasal cannula in proper position
with prongs curving downward
13. Place cannula prongs into nares
14. Wrap tubing over and behind ears
15. Adjust plastic slide under chin
until cannula fits snugly
16. Place gauze at ear beneath tubing
as necessary.
17. If prongs dislodge from nares,
replace promptly.
18. Assess for proper functioning of
equipment and observe client's initial
response to therapy.
19. Monitor continuous therapy by assessing
for pressure areas on the skin and nares
every 2 hours and rechecking flow rate
every 4 to 8 hours.
Document
20. Assessment data

21. Percentage or liter flow of
oxygen administration.
22. Type of delivery device
23. Length of time in use
24. Client’s response to oxygen therapy
TOTAL
70
Skill 9-2: Administering Oxygen via an Oxygen Mask

Needs Practice
Satisfactory
Goals: To monitor respiratory status of a patient

Excellent
with a chest tube; to ensure chest drainage system

is functioning adequately to promote lung
expansion. Comments
1 0.5 0
Assessment
1. Assess respiratory status (i.e., breath
sounds, respiratory rate and depth, presence
of sputum, arterial blood gases if available).
2. Assess past medical history, noting chronic
obstructive pulmonary disease (COPD). For
clients with COPD, hypoxemia is often the
stimulus to breathe because they
chronically have high blood levels of carbon
dioxide. If additional oxygen is needed, a
low-flow system is essential to maintain
slight hypoxemia so breathing is stimulated.
3. Assess for clinical signs and symptoms of
hypoxia: anxiety, decreased level of
consciousness, inability to concentrate,
fatigue, dizziness, cardiac dysrhythmias,
pallor or cyanosis, dyspnea.
Planning
4. Review chart for physician's order for oxygen
to ensure that it includes method of delivery,
flow rate, titration orders; identify client.
5. Identify client and proceed with 5 rights of
medication administration. Explain procedure
to client. Explain that oxygen will ease

dyspnea or discomfort, and inform client
concerning safety precautions associated with
oxygen use.
Implementation
6. Wash your hands
7. Assist client to semi- or high Fowler's
position, if tolerated.
8. Insert flowmeter into wall outlet. Attach
oxygen tubing to nozzle on flowmeter. If
using a high O2 flow, attach humidifier.
Attach oxygen tubing to humidifier.
9. Turn on the oxygen at the prescribed rate. For
a mask with a reservoir, be sure to allow
oxygen to fill bag
10. Place mask on face, applying from the
nose and over the chin
11. Adjust the metal rim over the nose
and contour the mask to the face.
12. Assess for proper functioning of
equipment and observe client's initial
response to therapy.
13. Monitor continuous therapy by assessing
for pressure areas on the skin and nares
every 2 hours and rechecking flow rate
every 4 to 8 hours.
Document
14. Document findings in the client record using
forms or checklists supplemented by
narrative notes when appropriate.
TOTAL

Skill 5-1: Inserting a Nasogastric (NG) Tube

NeedsPractice
Satisfactory
Excellent
Goals: Distal placement within the stomach is

confirmed, client exhibits no evidence of
respiratory distress, client can speak or hum, lung
sounds are present and clear bilaterally, no
bleeding or pain is noted in area of nasal mucosa Comments
1 0.5 0
Assessment
1. Check that a medical order has been written.
2. Determine the reason for the nasogastric
tube.
3. Identify the client.
4. Assess how much the client understands
about the procedure.
5. Inspect the nose after the client blows into a
paper tissue.
6. Unwrap and uncoil the tube.
7. Obtain the NEX measurements.
8. Mark the tube at the NE (nose-to-ear) and NX
(nose-to-xiphoid) measurements.
Planning
9. If a plastic tube feels rigid, place it in or flush
it with warm water.
10. Assemble the following equipment, in
addition to the tube: water, straw, towel,
lubricant, tissues, tape, emesis basin,
flashlight, stethoscope, clean gloves, 50-
mL syringe.
11. Place a suction machine at the bedside if

the client is unresponsive or has difficulty
swallowing.
12. Remove dentures.
13. Establish a hand signal for pausing.
Implementation
based handrub.
16. Assist the client to sit in semi-Fowler or high-
Fowler’s position and hyperextend the
neck as if in a sniffing position.
17. Protect the client, bedclothing, and linen
with a towel.
18. Don gloves.
19. Lubricate the tube with water-soluble gel over 6
to 8 inches (15 to 20 cm) at the distal tip.
20. Insert the tube into the nostril while
pointing the tip backward and downward.
21. Do not force the tube. Relubricate or rotate
it if there is resistance.
22. Stop when the first mark on the tube is at
the tip of the nose.
23. Use a flashlight to inspect the back of
the throat.
24. Instruct the client to lower his or her chin
to the chest and swallow sips of water.
25. Advance the tube 3 to 5 inches (7.5 to
12.5 cm) each time the client swallows.
26. Pause if the client gives the
preestablished signal.
27. Discontinue the procedure and raise the
tube to the first mark if there are signs of
distress such as gasping, coughing, a bluish
skin color, or the inability to speak or hum.
28. Assess placement when the second mark
is reached.
29. Withdraw the tube to the first mark and
reattempt insertion if the assessment
findings are inconclusive, or consult with the
physician about obtaining an x-ray.
30. Proceed to secure the tube if data

indicate the tube is in the stomach.
31. Connect the tube to suction or clamp it
while awaiting further orders.
32. Remove gloves and wash your hands or
use an alcohol-based hand rub.
33. Position the client with a minimum
head elevation of 30 degrees.
34. Remove equipment from the bedside.
35. Measure and record the volume of
drainage at least every 8 hours.
Document
36. Type of tube
37. Outcomes of the procedure
38. Method for determining placement
and outcome of assessment
39. Description of drainage
40. Type and amount of suction, if the tube
is used for decompression
TOTAL

NeedsPractice
Skill 5-2: Removing a Nasogastric (NG) Tube

Excellent
Satisfactory
Goals: Tube is removed, client resumes eating

and taking fluids, client experiences no nausea or
vomiting, airway remains clear, nasal mucosa is
moist and intact. Comments
1 0.5 0
Assessment
1. Assess bowel sounds, condition of mouth and
nasal mucosa, level of consciousness, and gag
reflex.
2. Check that a medical order has been written.
3. Identify the client.
4. Assess how much the client understands the
procedure.
Planning
5. Assemble the following equipment: towel,
emesis basin, cotton-tipped applicator sticks,
oral hygiene equipment, and clean gloves.
Implementation
handrub.
8. Place the client in a sitting position, if alert, or
in a lateral position if not.
9. Cover the chest with a clean towel and place
the emesis basin and tissues within easy
reach.
10. Remove the tape securing the tube to

the client’s nose.
12. Turn off the suction and separate tube.
13. Instill a bolus of air into the lumen that
drains gastric secretions.
14. Clamp, plug, or pinch the tube.
15. Instruct the client to take a deep breath
and hold it just before removing the
nasogastric tube.
16. Remove the tube from the client’s nose
gently and slowly.
17. Enclose the tube within the towel or glove
and discard the tube in a covered container.
18. Empty, measure, and record the drainage
in the suction container.
20. Offer an opportunity for oral hygiene.
21. Encourage the client to clear the nose
of mucus and debris with paper tissues
or cotton-tipped applicators.
22. Discard disposable equipment; rinse
and return portable suction equipment.
Document
23. Type of tube removed
24. Response of client
25. Appearance and volume of drainage
26. Appearance of nose and nasopharynx
TOTAL

NeedsPractice
Skill5-3:Administering Medications via Gastric Tube

Excell
Satisfactory
Goals: Tube placement is verified, the five rights are

ent
upheld, medications instill freely and are flushed

afterward, client experiences no abdominal distention,
nausea, vomiting, or other undesirable effects, tube
remains patent Comments
1 0.5 0
Assessment
1. Check the medication administration record (MAR)
and compare the information with the written
medical order.
2. Review the client’s drug, allergy, and medical history.
4. Verify the location of the tube by auscultating
instilled air or aspirating secretions.
5. Compare the length of the external tube with its
measurement at the time of insertion.
6. Inspect the client’s mouth and throat.
Planning
minutes of the scheduled time.
8. Separate and clamp or plug a feeding tube for 15 to
30 minutes if the drug will interact with food.
9. Allow sufficient time to prepare the medications in a
10. Make sure that there is a sufficient supply of plastic
medication cups.
Implementation

handrub.
MAR at least three times—before, during, and after
preparing the drug.
13. Prepare each drug separately.
14. Take to the bedside the cups containing diluted
medications, water for flushing, a 30- to 50-mL
syringe, a towel or disposable pad, and clean gloves.
15. Identify the client by checking the wristband or asking
the client’s name.
16. Help the client into a Fowler’s position.
18. Insert the syringe into the tube and instill 15 to 30 mL
of water by gravity.
19. Add the diluted medication to the syringe as it
becomes nearly empty.
20. Apply gentle pressure with the plunger or bulb of a
syringe if the medication fails to instill easily.
21. Flush with at least 5 mL of water between each
instillation of medication and as much as 30 mL after
instilling all the medications.
22. Pinch the tube as the syringe empties.
23. Clamp or plug the tube for 30 minutes before
reconnecting a tube to suction.
24. Connect a tube used for nourishment immediately if
the medication and formula will not interact.
25. Keep the head of the bed elevated for at least 30
minutes.
Document
26. Preadministration assessment data
28. Volume of fluid instilled with the medication as well
as for flushing the tube on the bedside intake and
output record
29. Response of the client
TOTAL


Satisfactory
NeedsPractice
Skill 7-3: Catheterizing the Female Urinary Bladder

Excelle
Goals: Catheter is inserted under aseptic

nt
conditions, urine is draining from the catheter,

and client exhibits no evidence of discomfort
during or after insertion. Comments
1 0.5 0
Assessment
1. Check the client’s record to verify that a
medical order has been written.
2. Inspect the medical record to determine if
the client has a latex allergy.
3. Determine the type of catheter that has
been prescribed.
4. Review the client’s record for documentation
of genitourinary problems.
5. Assess the client’s age, size, and mobility.
6. Assess the time of the last voiding.
about catheterization.
8. Familiarize yourself with the anatomic
landmarks.
Planning
9. Gather supplies which include a
catheterization kit, bath blanket, and
additional light, if necessary.
Implementation
10. Close the door and pull the privacy curtain.
11. Raise the bed to a high position.
12. Wash your hands or perform an

alcohol-based handrub.
13. Cover the client with a bath blanket and
pull the top linen to the bottom of the bed.
14. Position an additional light at the bottom
of the bed or ask an assistant to hold a
flashlight.
15. Use the corners of the bath blanket to
cover each leg.
16. Place the client in a dorsal recumbent
position with the feet about 2 feet apart.
17. Use a lateral or Sims’ position for clients
who have difficulty maintaining a dorsal
recumbent position.
18. If the client is soiled, don gloves, wash
the client, remove gloves, and perform
hand hygiene measures again.
19. Remove the wrapper from the
catheterization kit and position it nearby.
20. Unwrap the sterile cover to maintain
the sterility of the supplies inside.
21. Remove and don the packaged sterile gloves.
22. Remove the sterile towel from the kit
and place it beneath the client’s hips.
23. Place a fenestrated drape over
the perineum.
24. Open and pour the packet of antiseptic
solution (Betadine) over the cotton balls.
25. Test the balloon on the catheter by instilling
fluid from the prefilled syringe; then
aspirate the fluid back within the syringe.
26. Spread lubricant on the tip of the catheter.
27. Place the catheterization tray on top of
the sterile towel between the client’s legs.
28. Pick up a moistened cotton ball with the
sterile forceps and wipe one side of the
labia majora from an anterior to posterior
direction.
29. Discard the soiled cotton ball in the outer
wrapper of the catheterization kit; repeat
cleansing the other side of the labia majora.
30. Separate the labia majora and minora with

the thumb and fingers of the nondominant
hand, exposing the urinary meatus.
31. Consider the hand separating the labia to
be contaminated.
32. Clean each side of the labia minora with
a separate cotton ball while continuing to
retract the tissue with the nondominant
hand.
33. Use the last cotton ball to wipe centrally,
starting above the meatus down toward
the vagina.
34. Discard the forceps with the last cotton ball
into the wrapper for contaminated supplies.
35. Keep the clean tissue separated.
36. Pick up the catheter, holding it
approximately 3 to 4 inches (7.5 to 10
cm) from its tip.
37. Insert the tip of the catheter into the
meatus approximately 2 to 3 inches (5 to 7.5
cm) or until urine begins to flow.
38. Recheck anatomic landmarks if there is
no evidence of urine; remove an
incorrectly placed catheter and repeat,
using another sterile catheter.
39. Advance the catheter another 1/2 to 1 inch
(1.3 to 2.5 cm) after urine begins to flow.
40. Direct the end of the catheter so that it
drains into the equipment tray or
specimen container.
41. Hold the catheter in place with the fingers
and thumb that were separating the labia.
42. Pick up the prefilled syringe with the
sterile, dominant hand, insert it into the
opening to the balloon, and instill the fluid.
43. Withdraw the fluid from the balloon if the
client describes feeling pain or
discomfort, advance the catheter a little
more, and try again.
44. Tug gently on the catheter after the
balloon has been filled.
45. Connect the catheter to a urine
collection bag.
46. Wipe the meatus and labia of any

residual lubricant.
47. Secure the catheter to the leg with tape
or other commercial device.
48. Hang the collection bag below the level
of the bladder; coil excess tubing on the
mattress.
49. Discard the catheterization tray and
wrapper with soiled supplies.
50. Remove your gloves and perform
hand hygiene.
51. Remove the drape, restore the top sheets,
make the client comfortable, and lower
the bed.
Document
52. Preassessment data
53. Size and type of catheter
54. Amount and appearance of urine
TOTAL


Satisfactory
NeedsPractice
Skill 7-4: Administering A Cleansing Enema
Excellent
Goals: Sufficient amount of solution is instilled,

comparable amount of solution is expelled,
client eliminates stool. Comments
1 0.5 0
Assessment
1. Check the medical orders for the type of
enema and prescribed solution.
2. Check the date of the client’s last bowel
movement.
3. Wash hands or perform an alcohol-based
handrub.
4. Auscultate bowel sounds.
5. Determine how much the client
understands the procedure.
Planning
6. Plan the location where the client will
expel the enema solution and stool.
7. Obtain appropriate equipment including
an enema set, solution, absorbent pad,
lubricant, bath blanket, and gloves.
8. Plan to perform the procedure according
to the time specified by the physician or
when it is most appropriate during client
care.
9. Prepare the solution and equipment in
the utility room.
10. Warm the solution to approximately
105°F to 110°F (40°C to 43°C).
11. Clamp the tubing on the enema set.

12. Fill the container with the
specified solution.
Implementation
14. Place the client in a Sims’ position.
15. Drape the client exposing the
buttocks and place a waterproof pad
under the hips.
16. Don gloves.
17. Place (or hang) the solution container
so that it is 12 to 20 inches (30 to 50
cm) above the level of the client’s anus.
18. Open the clamp and fill the tubing
with solution. Reclamp.
19. Lubricate the tip of the tube generously.
20. Separate the buttocks well so that
the anus is in plain view.
21. Insert the tube 3 to 4 inches (7 to 10
cm) in an adult.
22. Direct the tubing at an angle pointing
toward the umbilicus.
23. Hold the tube in place with one hand.
24. Release the clamp.
25. Instill the solution gradually over 5
to 10 minutes.
26. Clamp the tube for a brief period while
the client takes deep breaths and
contracts the anal sphincters if
cramping occurs.
27. Resume instillation when cramping
is relieved.
28. Clamp and remove the tubing after
sufficient solution has been instilled
or the client states that he or she
cannot retain more.
29. Encourage the client to retain the solution
for 5 to 15 minutes.
30. Hold the enema tubing in one hand and
pull a glove over the inserting end of the
tubing.
31. Remove and discard the remaining glove
and dispose of the enema equipment.
32. Assist the client to sit while
eliminating the solution and stool.
33. Examine the expelled solution.
34. Clean and dry the client; help him or
her to a comfortable position.
Document
35. Type of enema solution
36. Volume instilled
37. Outcome of procedure
TOTAL

Skill 4-3: Turning And Moving A Client

Satisfactory
NeedsPractice
Excellent
Goals: Movement is achieved, client is

comfortable, pressure is relieved, joints and
limbs are supported Comments
1 0.5 0
Assessment
1. Assess for risk factors that may contribute
to inactivity.
2. Determine the time of the last position
change.
3. Assess physical, mental, and emotional
ability to assist in turning, positioning, or
moving.
4. Inspect for drainage tubes and equipment.
Planning
6. Remove all pillows and current positioning
devices, such as trochanter rolls.
7. Raise the bed to elbow height, which is a
suitable working height.
8. Secure two or three additional caregivers,
positioning and moving devices (e.g., roller
sheets, repositioning sling, mechanical lift),
or both as needed.
9. Close the door or draw the bedside curtain.
Implementation
Turning the Client From Supine to Lateral or
Prone Position
10. Wash hands or perform an alcohol-

based hand rub when appropriate.
11. Lower the side rail and have the client
slide to one side of the bed.
12. Raise the side rail.
13. Move to the other side of the bed
and lower the side rail on that side.
14. Flex the client’s far knee over the near
one with the arms across the chest.
15. Spread your feet, flex your knees, and
place one foot behind the other.
16. Place one hand on the client’s shoulder
and one on the hip on the far side.
17. Roll the client toward you.
18. Replace pillows behind the back and
between the legs and under the upper arm.
19. Raise the side rails and lower the height
of the bed.
For a Prone Position
21. Begin as described earlier for the
lateral position.
22. Have the client turn his or her head
opposite to the direction for rolling and
leave the arms extended at each side.
23. Shift your hands from the posterior of
the shoulder and hip to the anterior as
the client rolls independently onto his or
her abdomen.
24. Center the client in bed.
25. Arrange pillows.
26. Raise the side rails and lower the height
of the bed.
Moving the Mobile Client Up in Bed
(One-Nurse and Client Technique)
29. Remove pillow from under the

client’s head.
30. Place the pillow against the headboard.
31. Raise the bed to elbow height.
32. Place a roller/slider sheet beneath the
buttocks, if one is not already present,
to facilitate movement if needed.
33. Instruct the client to grasp a trapeze and
bend both knees while keeping the feet
flat on the bed.
34. Ask the client to pull on the trapeze and
push down with his or her feet, causing
the legs to straighten. Repeat again if
necessary.
35. Rearrange pillows and remove the roller
sheet unless it will be needed again in
the near future.
36. Place the client in a slight Trendelenburg
position if sliding downward is a
persistent problem.
Two-Nurse and Roller Sheet Technique
39. Protect the headboard with a pillow.
40. Raise the bed to elbow height
41. Place a roller/slider sheet beneath
the client’s shoulders and buttocks.
42. Stand facing each other on opposite
sides of the bed between the client’s
hips and shoulders.
43. Roll the slider sheet to the sides of
the client.
44. Grasp the rolled sheet with the palms
up and the knuckles in contact with the
bed sheet.
45. Bend hips and knees; spread feet.
46. Slide the client up on reaching a previously
agreed signal, such as the count of three.
47. Avoid shrugging the shoulders

while moving the client
48. Rearrange pillows; remove the roller
sheet unless it will be needed again in the
near future.
49. Place the client in a slight Trendelenburg
position if sliding downward is a
persistent problem.
50. Wash hands or use an alcohol-based
hand rub when appropriate.
Document
51. Frequency of turning and moving
52. Positions used
53. Use of positioning devices
54. Assistance required
TOTAL

Skill 4-4: Transferring Clients

NeedsPractice
Satisfactory
Excellent
Goals: Client is relocated, no injury occurs to client

or personnel. Comments
1 0.5 0
Assessment
1. Check the Kardex, nursing care plan, and
medical orders for activity level.
2. Assess the client’s strength and mobility, as
well as his or her mental and emotional status.
Planning
3. Consult with the client on the preferred time
for getting out of bed.
4. Locate a straight-backed chair, wheelchair, or
stretcher to which the client will be
transferred.
5. Arrange the chair or stretcher next to or close
to the bed on the client’s stronger side, if
there is one.
6. Lock the wheels of the bed, wheelchair, or
stretcher.
7. Explain how the transfer will be accomplished.
Implementation
From Bed to Chair
8. Wash hands or perform an alcohol-based hand
rub when appropriate.
9. Assist the client to a sitting position on the
side of the bed.
10. Help the client don a bathrobe and

nonskid slippers.
11. Place the chair parallel to the bed on the
client’s stronger side; raise the footrests if
the client is using a wheelchair.
12. Apply a transfer belt or other assistive
device, if needed.
13. Grasp the transfer belt or reach under
the client’s arms.
14. Instruct the client to grasp your shoulders.
15. Bend the hips and knees; brace the
client’s knees.
16. Rock the client to a standing position at an
agreed signal while encouraging the client
to straighten his or her knees and hips.
17. Pivot the client with his or her back
toward the chair.
18. Tell the client to step back until he or she
feels the chair at the back of the legs.
19. Instruct the client to grasp the arms of the
chair while you stabilize his or her knees
and lower the client into the chair.
20. Support the feet on the footrests.
Using a Transfer Board
hand rub when appropriate.
22. Remove an arm from the wheelchair.
23. Slide the client to the edge of the bed.
24. Angle the transfer board from the client’s
buttocks and hips down toward the seat of
the chair.
25. Position the transfer board beneath the client.
26. Support and brace the client’s knee with
your knees while maintaining proper body
mechanics.
27. Slide the client down the transfer board into
the seat of the chair at an agreed-on signal.
hand rub if appropriate.
Using a Mechanical Lift

30. Raise the bed to a height that places the
client near the nurse’s center of gravity.
31. Lock the brakes on the bed.
32. Place the canvas sling under the client
from the shoulders to midthigh.
33. Move the lift device on the same side of
the bed as the chair or stretcher to which
the client will be transferred.
34. Position the boom on the lift over the
client’s torso.
35. Lock the wheels on the lift.
36. Attach the hooks on the lifting chain or
straps to the holes in the canvas sling.
37. Position the client’s arms across his or
her chest.
38. Pump the jack handle to elevate the client
to about 6 inches above the mattress.
39. Unlock the wheels on the lift and move the
lifted client directly over the chair or stretcher.
40. Relock the wheels of the lift.
41. Release the jack handle slowly.
42. Remove the lifting chains, but leave the
canvas sling in place beneath the client.
Document
44. Method of transfer
45. Response of client
TOTAL


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‫اململكة العربية السعودية‬

KINGDOM OF SAUDI ARABIA

Dr.Zainab Albikawi RN,MSN, PhD

Skill 2-1:Assessing Body Temperature

Goals: Thermometer remained inserted the

if needed. Include lubricant, paper tissues,

3. Position the client on the side with the

1. Remove the thermometer component

tympanic thermometer since it was

Instructor/ Evaluator’s Signature Student’s Signature

Goals: Pulse rate remained palpable throughout

11. Raise the height of the bed.

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date:

Instructor/ Evaluator Name:

Skill 2-3: Assessing The Respiratory Rate

11. Wash hands or perform hand antisepsis

Instructor/ Evaluator’s Signature Student’s Signature

Skill 2-4: Assessing Blood Pressure

Goals: Korotkoff sounds are heard clearly, blood

11. Plan to use the right or left arm

30. Control the release of air at a rate of

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date:

Instructor/ Evaluator Name:

Skill 9-1: Monitoring with Pulse Oximetry

Goals: SpO2 measurements remain within 95% to

addition, there are clip-on, adhesive, and

17. Nursing measures to improve oxygenation

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date:

Instructor/ Evaluator Name:

Skill 1-1: Performing Hand Hygiene Using Soap and Water

Goal: Hand washing has met time requirements,

10. Dispense about 3 to 5 mL (1 tsp) of liquid soap

5. Rinse the soap from your hands by letting the

Instructor/ Evaluator’s Signature Student’s Signature

Skill 1-2: Performing Hand Hygiene Using an Alcohol –

Based Hand Rub

Goal: Transient microorganisms are eliminated

e. Backs of fingers to opposing palms with

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date:

Instructor/ Evaluator Name:

Equipment (Gloves, Gown, Mask, Eyewear)

clients free from transmission of potential

8. Perform hand hygiene

a gown, pull the gloves up to cover the

b. If using a mask with strings, first untie

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date:

Instructor/ Evaluator Name:

Skill 6-1: Giving a Bed Bath

Goals: Client is completely bathed, client

10. Remove the client’s gown.

29. Remove gloves and help the client to don

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date:

Instructor/ Evaluator Name:

Goals: The teeth are clean, the oral mucosa is

9. Connect a Yankeur suction tip or catheter to a

Instructor/ Evaluator’s Signature Student’s Signature

Student’s Name: Date: