checkist for ncm 100 (skills) (2)

COLLEGE OF NURSING PERFORMANCE EVALUATION TOOL

FUNDAMENTALS OF NURSING PRACTICEHYGIENE

SHAMPOOING and COMBING THE HAIRPROCEDURE 5 4 3 2 1 REMARKIdentify yourself. Explain the procedure to the client or relativeAssist patient to the sink. If patient cannot walk alone, provide a weight gait device or wheelchair. (apply techniques in transferring client from bed to wheelchair or chair or stretcher)Perform hand hygiene and other infection controlWear gloves if needed Position wheelchair at the sink with the back facing youPut a towel on the patient’s shoulder and a rolled towel under the patient’s neck/napePut a piece of cotton ball inside the two ears and a dampen wash cloth over their eyes to prevent water from entering the eyes and ears (remove eye glasses)Adjust the water temperature.With the use of a shower tool, wet hair thoroughlyApply shampoo and work on a lather. > Massage scalp using finger pads not the finger nails in circular motion to promote blood circulation and relaxation. Rinse well, shampooing may be repeated twiceSqueeze the end of the hair strands to remove excess water and dry well.Assist patient to raise his/her head off the sink. Put a dry towel around head.Continue drying the hair. Use hair dryerComb and style hair according to patient’s preferences. Avoid juvenile hairstyle if client is an older client

Place a towel across the shoulders. Place a towel across the pillow if the patient is in bed

Part the hair and divide it into two (2) main sections. Divide one side into two (2) sections.

Brush/ comb the hair. Start at the scalp and brush toward the hair ends

Remove the towel Let the patient put on the eye glasses.

Assist client to assume a comfortable position

Offer a mirror to the client for viewing himself/herselfPlace the signal light within reach Put all soiled materials in a hamper. Rearrange materials to its proper places.Remove gloves and do hand washingDocument procedures in the patient’s chart.

Student’s Signature:_______________ Instructor’ Signature________________Date:_____ Date:__________

Comments/Suggestions:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Eye carePROCEDURE 5 4 3 2 1 REMARKPosition on a sitting positon or lying position.Dip one cotton ball into a clean water, squeeze and wipe each eye starting from the inner canthus going to outer canthus. Throw the used cotton ball into a plastic containerRepeat procedure on the other eye

Use separate cotton balls on each eyeDocument the procedure and other pertinent data on the patient’s chart such as: redness, eye discharge





ShavingPROCEDURE 5 4 3 2 1 REMARKIdentify the patient. Introduce self. Explain the procedure.Gather the needed materials:

Wash basin Wash cloth Face towel Bath towel bath thermometer mirror shaving cream or soap shaving brush razor or shaver After shave lotion/cologne Tissues Paper towel Disposable gloves

Place the paper towels on the overbed table. Arrange items on top of it.Provide for privacy.Raise the head of the bed to a level for good body mechanics.Fill the wash basin. Water temperature should be approximately 115 degrees F (46 degrees C)Place the basin on the overbed table on top of the paper towels.Lower the side rail.Position the patient in semi Fowler’s position if allowed or tolerated or on his backAdjust lighting so that you can clearly see the patient’s face.Place the bath towel over the chest.Position the overbed table within easy reach and at a comfortable working height.Put on the gloves.Wash the patient’s face. Do not dry.

PROCEDURE 5 4 3 2 1 REMARKPlace a washcloth or face towel in the water and wet it thoroughly. Wring it out.Apply the wash cloth or towel to the patient’s face to soften the beard. Remove it after 3 to 5 minutes.Apply shaving cream to the face with your hands. If apply lather, use a shaving brush.Tighten the razor blade to the razor.Hold the skin taut with your non-dominant handShave in the direction of hair growth. Use shorter strokes around the chin and lipsRinse the razor often and wipe with tissues.Apply direct pressure to any bleeding areas.Wash off any remaining shaving cream or soap. Dry with a towel.Apply after shave lotion if requestedMove the overbed table to the side of the bed.Remove the gloves.Make sure the patient is comfortable and safe.Place the signal light within reachRaise the side railLower the bed to its lowest position.Clean and return equipment and supplies to their proper place. Discard disposable itemsWipe off the overbed table with the paper towels. Discard the paper towels.Unscreen the patientPlace soiled linen in the linen hamper.Wash your hands.Document the procedure on the patient’s chart and report any nicks or bleeding to the physician.





Oral Hygiene/Mouth Hygiene: a. ASSISTING THE PATIENT TO BRUSH THE TEETH

PROCEDURE 5 4 3 2 1 REMARKIdentify the client. Introduce self. Explain the procedure to the patient and relative. Gather the needed materials.

Toothbrush > face towel Toothpaste or dentrifice > paper towels Mouthwash > clean gloves Dental floss > Water glass with

cool Straw water Emesis basin

Place the paper towels on the overbed table. Arrange items on top of it.Wash handsRaise the head of the bed to a level where the patient can brush with ease.Place the towel over the patient’s chest to protect the gown and linen from spills.Lower the side rail for your working areaMove the overbed table in front of the patient. Adjust the table height so that the patient can work on easeAllow the patient to brush the teeth.Move the overbed table next to the bed when the patient is finished. Lower it to a level appropriate for the patientMake sure the patient is comfortablePlace the signal light within the patient reachRaise the side railClean and return equipment to its proper place.Wipe off the overbed with the paper towels and discard it properly.Unscreen the patient.Place soiled linen in the linen hamper

PROCEDURE 5 4 3 2 1 REMARKWash hands.Document or report observations to the doctor.





Oral Hygiene/Mouth Hygiene: b. BRUSHING THE PATIENT’S TEETH

PROCEDURE 5 4 3 2 1 REMARKIdentify the client. Introduce self. Explain the procedure to the patient and relative.Wash hands.Gather the needed materials.Place the paper towels on the overbed table. Arrange items on top of it.Provide for privacyRaise the head of the bed to a level for good body mechanicsRaise the head of the bed so that the patient can sit comfortablyPosition the patient on the side near you if he or she cannot sit upLower the side railPlace the towel over the patient’s chest to protect the gown and linen from spills.Position the overbed table so that you can reach it with ease. Adjust the height as needed.Put on the gloves.Apply toothpaste to the tooth brush.Hold the tooth brush over the emesis basin. Pour some water over the brushBrush the patients teeth gently.Let the patient have some water to rinse the mouth. Hold the emesis basin under the patient’s chin. Have the patient repeat rinsing as necessary.Floss the patient’s teethLet the patient use mouthwash. Hold the emesis basin under the chin.Remove and discard the gloves.Make sure the patient is comfortable.

PROCEDURE 5 4 3 2 1 REMARKPlace the signal light within reach of the patientRaise the side rail.Lower the bed to its lower positionClean and return the materials to its proper placeWipe off the overbed table with the paper towels and discard them.Unscreen the patientPlace soiled linen in the linen hamperWash handsDocument/report your observations to the physician





c. FLOSSING THE PATIENT’S TEETH

PROCEDURE 5 4 3 2 1 REMARKIdentify the patient. Introduce yourself. Explain the procedureWash handsGather the necessary materialsPlace the paper towels on the overbed table. Arrange items on top of it.Provide for privacy.Place the bed an appropriate level for good body mechanicsRaise the head of the bed so that the patient can sit comfortably. Position the client on the side near you if he or she cannot sit up.Place the towel over the patient’s chest to protect the gown and linens from spillsPosition the overbed table so that you can reach it with ease. Adjust the height as needed.Wash your handsLower the side rail.Put on the glovesBreak off an 18 inches pc. of floss from the dispenserHold the floss between the middle finger of each handStretch the floss with your thumbsStart at the upper back tooth on the right side and work around to the left sideMove the floss gently up and down between the teethMove to a new section of floss every second toothFloss the lower teeth. Hold the floss with your index fingers. Use back and forth motions and go under the gums as you did for the upper teeth. Start on the right side and work around to the left sideLet the patient rinse his /her mouth. Hold the emesis basin under the chin. Repeat rinsing as necessary.

PROCEDURE 5 4 3 2 1 REMARKFollow steps 19 t0 20 for brushing the patient’s teethd. DENTURE CAREIdentify client. Introduce self. Explain the procedureCollect needed materials:

Emesis basin Towel Denture cup Gloves Gauze square Toothbrush Tooth paste

Wash your hands.Provide for privacy.Lower the side rail.Place the towel over the patient’s chestAsk the patient to remove the dentures. Carefully place them in the emesis basinIf the patient cannot do so, put on gloves and remove the dentures using gauze squaresRaise the side rail.Take the emesis basin, denture cup, brush, and denture cleaner or toothpaste to the sinkRinse each denture under warm running water. Return them to the denture cup.Line sink with a towel and fill it with water.Apply denture cleaner or toothpaste to the brush.Brush the dentures.Rinse the dentures under warm running water. Handle them carefully, do not drop them.Place the denture in the denture cup. Fill it with cool water until the dentures are covered.Clean the emesis basin.Bring the denture cup and emesis basin to the bedside tableLower the side rails.Position the patient for oral hygiene.Assist the patient to rinse out his or her mouth with mouth wash. Hold the emesis basin under the chinAsk the patient to insert the dentures. You must insert them if the patient cannot.Remove the gloves.

PROCEDUREPut the denture cup in the top drawer of the bedside stand if the dentures are not reinsesrtedMake sure the patient is comfortableMake sure the signal light is within reachRaise the side rails.Unscreen the patientClean and return equipments to its proper place. Discard disposable materialsPlace soiled linen in the linen hamper.Wash your handsDocument procedure in the patient’s chart and other pertinent data. Report observations to the doctor.





GIVING FEMALE PERINEAL CARE

PROCEDURE 5 4 3 2 1 REMARKIdentify the patient. Introduce self. Explain the procedure.Gather the needed materials

Soap dish with soap Three to ten disposable washclots or a small

package of cotton balls Bath towel Bath blanket Bath thermometer Waterproof pad Disposable gloves Paper towels Disposable bags

Place the paper towels on the overbed table. Arrange items on top of it.Provide for privacy.Raise the bed to a level appropriate for good body mechanicsLower the side rail.Cover the patient with a bath blanket. Move top linens to the foot of the bed.Position the waterproof pad under her buttocksDrape the patientRaise the side rail.Fill the wash basin. Water temperature should be approximately 105 degrees F to 109 degrees F ( 41-43 degrees C)Place the basin on the overbed table on top of the paper towels.Lower the side rail.Help the patient flex her knees and spread her legs.Put on the glovesPut the washcloth in the basin. Squeeze out excess water before using them.

Apply soap to a washcloth

PROCEDURE 5 4 3 2 1 REMARKSeparate the labia. Clean downward from front to back with one stroke. Discard the washcloth into the disposable bag.

Use a mitted washclothRepeat 17 and 18 until the area is clean.Rinse the perineum with a washcloth. Separate the labia. Stroke downward from front to back.Pat the area dry with towel.Fold the blanket back between the client’s legsHelp the patient lower her legsRemove the waterproof pad under the client’s buttocks. Remove gloves and discard them into the bag.Return linens to their proper position remove the bath blanket.Raise the side rail. Place the signal light within reach.Lower the bed to its lowest position.Clean and arrange reusable materialsDiscard all non reusable materials.Wipe off the overbed table with the paper towels and discard themUnscreen the patient.Remove gloves and do hand washingDocument the procedure in the patient’s chart and other pertinent data such as:

a. a. Any odorsb. Redness, swelling, discharge or irritationc. Patient complaints of pain, burning or other

discomforts





GIVING NAIL AND FOOT CAREPROCEDURE 5 4 3 2 1 REMARKIdentify the patient. Introduce self. Explain the procedure.Gather the needed materials

Wash basin Bath thermometer Bath towel Face towel Wash cloth Emesis basin Nail clippers Orange stick Emery board or nail file Lotion or petroleum gel Paper towels Disposable bath mat

Place the paper towels on the overbed table. Arrange items on top of it.Provide for privacy.Help the patient to a bedside chair. Place the signal light within reach.Place the bath mat under the patient’s feet.Fill the wash basin. Water temperature should be 109 degrees F to 111 degrees F (43 to 44 degrees C)Put on gloves.Place the basin on the bath mat. Help the patient put the feet into the basin.Position the overbed table in front of the patient. It should be low and close to the patient.Fill the emesis basin. Water temperature should be 109 degree F to 111 degrees F ( 43 to 44 degrees C).Place the basin on the overbed table on top of the paper towels.Place the patient’s fingers into the basin. Position the

arms so that he or she is comfortableLet the feet and fingernails soak for 20 to 30 minutes. Re warm the water in 10 to 15 minutesClean under the fingernails with the orange stick.PROCEDURE 5 4 3 2 1 REMARKRemove the emesis basin and dry the fingers thoroughlyClip fingernails straight across with the nail clippers.Shape nails with an emery board or nail file.Push cuticles back with the orange stick or a washclothMove the overbed table to the side.Scrub callused areas of the feet with a washclothRemove the feet from the basin. Dry thoroughly.Apply lotion or petroleum gel to the feet.Assist the patient back to bed and to a comfortable position. Place signal light within reach.Raise the side rail.Clean and return equipment and supplies to their proper place. Discard disposable suppliesUnscreen the patient.Take soiled linen to the “dirty” utility roomRemove gloves and do hand washing.Document the procedure in the patient’s chart and other pertinent data such as:

a. reddened, irritated or callused areasb. Breaks in the skin





GIVING A BACK MASSAGEPROCEDURE 5 4 3 2 1 REMARKIdentify the patient. Introduce self. Explain the procedure.Gather the needed materials:

Bath blanket lotion Bath towel

Wash handsProvide for privacy.Raise the bed to an appropriate level for good body mechanics.Lower the side rail.Position the patient in the prone or side lying position. With the client’s back toward you.Expose the back, shoulders, upper arms, and the buttocks. Cover the rest of the body with bath blanket.Lay the towel on the bed along the backWarm the lotion bottle lotion under running water or rub some lotion between your handsExplain that the lotion may feel cool and wet.Apply lotion to the lower back area.Stroke up from the buttocks to the shoulders. Stroke down over the upper arms. Stroke up the upper arms, across the shoulders, and down the backs to the buttocks. Use firm strokes. Keep your hands in contact with the patient skin.Repeat step 13 for at least three minutesKnead by grasping tissue between your thumb and fingers. Knead half of the backs starting at the buttocks and moving up to the shoulders. Then knead down from shoulders to the buttocks. Repeat on the other half of the backMassage bony areas. Use circular motion with the tips

of your fingers and tips of middle fingers.

PROCEDURE 5 4 3 2 1 REMARKUse fast movement to stimulate and slow movement to relax the patient.Stroke with long, firm movements to end the massage, tell the patient you are finishing.Cover the patient. Remove the towel and bath blanket.Make sure the patient is comfortable.Raise the side rail. Place the signal light within reach.Lower the bed to its lowest position.Return the lotion to its proper place.Unscreen the patientPlace soiled linen in the linen hamper.Wash your hands.Document the procedure in the patient’s chart and other pertinent data





Changing Hospital GownsPROCEDURE 5 4 3 2 1 REMARKIdentify patient. Introduce yourself. Explain the procedure.Wash your handsProvide for privacyUntie the back of the gown. Free parts of the gown that the patient is lying on.Remove the gown from the arm with no IV.Gather up the sleeve of the arm with the IV. Slide it over the IV site and tubing.

Remove the arm and hand from the sleeveKeep the sleeve gathered. Slide your arm along the tubing to the bottle.Remove the bottle from the pole. Slide the bottle and tubing through the sleeve. Do not pull on the tubing. Keep the bottle above the patient’s arm.Hang the iv bottle on the pole.Gather the sleeve of the clean gown that will go on the arm with the IV infusion.Remove the bottle from the pole. Quickly slip the gathered sleeve over the bottle at the shoulder part of the gown.Slide the gathered sleeve over the tubing, hand, arm and IV site. Then slide the sleeve onto the patient’s shoulder.Put the other side of the gown on the patientFasten the back of the gown.Make sure the patient is comfortablePlace the signal light within reach.Raise the side rail. Lower the bed to its lowest position.Unscreen the patient.Take soiled linen to the “dirty” utility roomWash your hands


Comments/Suggestions:________________________________________________________________________________________________________________________



Complete Bed bathPROCEDURE 5 4 3 2 1 REMARKIdentify the client. Introduce self. Explain the procedure to the patient and relativeGather necessary materials:

Basin > clean gown Soap (optional) > Deodorant Wash cloth > Comb or brush 2 towels > Disposable gloves Bath blanket Lotion Materials for shampooing Materials for eye care Materials for oral care Materials for perineal care Materials for foot and nail care Materials for changing the bed linen Clean hospital gown

Place supplies over the bedside table.Fill basin with warm waterPerform hand hygiene and other infection controlWear gloves (clean gloves) if you are about to handle secretions, excretions, urine, feces, soiled linens or other body fluids.Provide privacy.Lower the side rails where you will work.Offer bed pan or urinals if patient wishes to urinate first. Side rails up. Discard the urine. Handwash and wear a new, clean gloves.Ask the patient to remove eye glasses if with these. Put eye glasses in the glass case. Put the case inside the bedside stand.Place towel over the patient’s chest.Perform shampooing and combing the hair procedure

(follow shampooing and combing the hair procedure)Perform eye care (follow eye care procedure)Perform oral care (follow oral care procedure)

PROCEDURE 5 4 3 2 1 REMARKPerform shaving the beard and mustache (follow procedure for these)While maintaining the cover of the arm farthest from you with a bath blanket, uncover the arm near you, place a towel lengthwise under this arm, wash, rinse and dry it paying attention on the axilla or armpit.

Use a circular motion with a mitten on your dominant hand.

Make a mitten of washcloth in handWhile maintaining the cover of the leg farthest from you with a bath blanket, uncover the leg near you, place a towel lengthwise under this leg, wash, rinse and dry it paying attention on behind leg.

Use a circular motion with a mitten on your dominant hand.

Make a mitten of washcloth in handPut patient on his side away from you. Let patient hold on the raised side rail or put a pillow in between legs. Put towel in a lengthwise mannerWash, rinse and dry back and buttocks in a circular motion with a mitten on your dominant hand.Apply and rub lotion on the patient’s back and buttocks.Repeat the procedure on the other side of arm and leg

Refill water as needed Always side rail up before leaving the patient on

bedPerform perineal care. Follow procedure.Change the client’s gown (Follow procedure)Perform bed making( occupied or unoccupied). Follow procedure.Place patient in a comfortable position. Place signal light within patient’s reach. Side rails up.Remove all soiled materials and discard them properly according to agency policyClean and return other materials to its proper places.Remove and discard glo’ves properly and wash hands.Inform relatives/visitors that they may return to the roomDocument procedures and other pertinent data on the

client’s chart.Student’s Signature:_______________ Instructor’ Signature________________Date:_____ Date:__________

Comments/Suggestions:__________________________________________________


FUNDAMENTALS OF NURSING PRACTICE

CHANGING LINENS IN AN UNOCCUPIED BEDPROCEDURE 5 4 3 2 1 REMARK

1Identify the patient, introduce self and explain the procedure

2Gather the necessary materials:

Bottom sheet Draw sheet Mattress pad Top sheet Pillowcase Antiseptic solution, Washcloth, and towel Nonsterile gloves (2 pairs) Linen bag hamper

3 Assess condition of blanket and or/bedspread4 Gather linens and gloves.

5Place linens on a clean, dry surface in reverse order of usage at the client’s bedside ( pillowcases, top sheet, draw sheet , bottom sheet

6 Apply gloves

7Inquire about the client’s toileting needs and attend as necessary

8 Assist client to a safe, comfortable chair

9Position bed: flat, side rails down, adjust height to a waist level

10Remove and fold blanket and or bed/spread.

If clean and reusable, place on clean work area

11Remove soiled pillowcases by grasping the closed end with one hand and slipping the pillow out with the other

Place the soiled cases on top of the soiled sheet, and place the pillows on clean work area

12Remove soiled linens:

Start on the side of the bed closest to you Free the bottom sheet and mattress pad by

lifting the mattress and rolling soiled linens to

the middle of the bedGo to the other side of the bed, repeat action

PROCEDURE 5 4 3 2 1 REMARK

13Fold soiled linens:

Head of bed to middle, foot of bed to middle Place in linen bag or hamper, keeping soiled

linens away from uniform

14Check mattress.> If the mattress is soiled, clean it with antiseptic solution and dry it thoroughly

15Remove gloves, wash hands, and apply a second pair of clean gloves

16Open the clean mattress pad lengthwise onto the bed with the seamed side of the sheet toward the mattress.> Unfold half of the pad’s width to the center crease and smooth the pad flat.> If there are elastic bands to hold the pad in place, slide them under the corners of the mattress

17Proceed with placing the bottom sheet onto the mattress.





CHANGING LINENS IN AN OCCUPIED BEDPROCEDURE 5 4 3 2 1 REMARK

1Identify the patient, introduce self and explain the procedure

2Gather the necessary materials:

Linen hamper Pillowcase Bath blanket Top sheet, draw sheet, bottom sheet Blanket Nonsterile gloves (2 pairs)

3 Bring equipment to the bedside4 Apply gloves

5Remove top sheet and blanket.

Loosen bottom sheet at foot and sides of bed Lower side rail nearest to you if necessary for

access Client may be covered with a bath blanket

6 Position client on side, facing away from you Reposition pillow under head

7Fanfold or roll bottom linens close to client toward the center of the bed

8 Smooth wrinkles out of mattress. Place clean bottom linens with the center fold

nearest the client Fan-fold or roll clean bottom linens nearest

client and tuck under soiled linen. Maintain an adequate amount of sheet at head

and foot of bed for tucking

9Mitter bottom sheet at head of bed, then at foot of bed.

To miter, lift the mattress and tuck the sheet over that e edge of the mattress, lift edge of sheet that is hanging to form a triangle and lay upper part of sheet back onto bed

Tuck the lower hanging section under the

mattress Repeat for each corner Tuck the sides of the sheet under the mattress

PROCEDURE 5 4 3 2 1 REMARK10 Fold the draw sheet in half

Identify the center of the draw sheet and place it close to the client

Fan-fold or roll-draw sheet closest to the client and tuck under soiled linen

Smooth linen Add protective padding if needed Tuck draw sheet under mattress, working from

the center to the edges Draw sheet should be positioned under the

lower back and buttocks11 Log roll client over onto side facing you.

Raise side rail12 Move to other side of bed

Remove soiled linens by rolling into a bundle and place in linen hamper without touching uniform

13. Unfold/unroll bottom sheet, then draw sheet Look for objects left in the bed Grasp each sheet with knuckles up and over

the sheet and pull tightly while leaning back with your body weight

Client may be positioned supine14 Place top sheet over client with center of sheet in

middle of bed Unfold top of sheet over client Remove bath blanket left on client to prevent

exposure during bed making Place top blanket over client, same as the top

sheet15. Raise foot of mattress and tuck the corner of the top

sheet and blanket under Mitter the corner Repeat with other side of mattress

16 Grasp top sheet and blanket over client’s toes and pull upward, then make a small fan-fold in the sheet

17. Remove soiled pillowcase Grasp center of clean pillowcase and invert

pillowcase over hand or arm Maintain grasp of pillowcase while grasping

center of pillow Use other hand to pull pillowcase down over

pillow

PROCEDURE 5 4 3 2 1 REMARK Place pillow under client’s head While changing pillowcase, client can be

instructed to rest head on bed, or place a blanket under client’s head

18 Document procedure used to change linen’s and client’s condition during the procedure

19 Remove gloves and wash hands.





SAFE WALKINGPROCEDURE 5 4 3 2 1 REMARK

1 Identify client. Introduce self and explain the procedure

2 Elevate the head of the bed and wait for several minutes

3 Lower the bed height4 With one arm on the client’s back and one arm under

the client’s upper legs, move the client into the dangling position.

5Encourage the client to dangle at side of the bed for several minutes

6 Place gait belt around client’s waist ; secure the buckle in front

7Stand in front of client with your knees touching the client’s knees

8 Place arms under client’s axilla.

9Assist client to a standing position, allowing client time to balance

10 Help the client ambulate the desired distance or distance of tolerance by placing your hand under the client’s forearm and ambulating close to the client

11 Help the client back to the bed or chair.12 Make the client comfortable and make sure all lines

and tubes are secure13 Document the activity14 Wash hands.





ASSISTING WITH CRUTCHES, CANE OR WALKERASSISTIVE DEVICES

A. CRUTCH WALKING PROCEDURE 5 4 3 2 1 REMARK

1Identify the client. Introduce yourself and explain the procedure ( that you will be assisting with ambulation using crutches)

2Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties and balance (collaborate with the physical therapist)

3 Adjust crutches to fit the client. With the client supine, measure from the heel

to the axilla With the client standing, set the crutch position

at a point 4 to 5 inches lateral to the client and 4 to 6 inches in front of the client

The crutch pad should fit 1.5 to 2 inches below the axilla (3 finger width)

The hand grip should be adjusted to allow for the client to have elbows bent at 30 degrees flexion

4 Lower the height of the bed.

5Dangle the client at the side of the bed for several minutes

Assess for vertigo6 Instruct client on method to hold the crutches: that is,

with elbows bent 30 degrees and pad 1.5 to 2 inches below the axilla

Instruct client to position crutches lateral to and forward of feet.

Demonstrate correct positioningApply the gait belt around the client’s waist if balance

7 and stability are unreliable8 Assist the client to a standing position with crutches.

Stand close to the client to support as needed

9. Document procedure and the client’s condition during the procedure

10. Wash hands




a.1 FOUR POINT GAIT

PROCEDURE5 4 3 2 1 REMARK

Position the crutches 4.5 to 6 inches to the side and in front of each foot

Move the right crutch forward 4 to 6 inches and move the left foot forward even with the left crutch

Move the left crutch forward 4 to 6 inches and move the right foot forward, even with the right crutch.

Repeat the four point gaita.2 THREE POINT GAIT

Advance both crutches and the weaker leg forward together 4 to 6 inches.

Move the stronger leg forward, even with the crutches

Repeat the three point gaita.3 TWO POINT GAIT

Move the left crutch and right leg forward 4 to 6 inches

Move the right crutch and left leg forward 4 to 6 inches

Repeat the two point gaita.4 SWING THROUGH GAIT

Move both crutches forward together 4 to 6 inches

Move both legs forward together in a swinging motion, even with the crutches

Repeat the swing through gait






WALKING UP STAIRSPROCEDURE 5 4 3 2 1 REMARK

Stand beside and slightly behind the client. Instruct client to position the crutches as if

walking Place body weight on hands Place the strong leg on the first step Pull the weak leg up and move the crutches up

to the first step Repeat for all steps

WALKING DOWN THE STAIRS PROCEDURE

1

Position the crutches as if walking Place weight on the strong leg Move the crutches down to the next lower step Place partial weight on hands and crutches Move the weak leg down to the step with

crutches Put total weight on arms and crutches Move strong leg to same step as weak leg and

crutches Repeat for all steps A second caregiver standing behind the client

holding on to the gait belt will further decrease the risk of falling

2. Consult with physical therapist for clients learning to walk with crutches

3 Wash hands

4Document procedure and the client’s condition during the procedure






b.WALKING WITH A CANE

PROCEDURE 5 4 3 2 1 REMARK1 Identify the client, introduce self and explain the

procedure2 Lower the height of the bed

Dangle the client at the side of the bed for several minutes

3 Assess client for strength, mobility, range of motion, visual acuity, perceptual difficulties and balance. Note: coordinate with the physical therapy

4 Apply the gait belt around the client’s waist if balance and stability are unreliable

5 Have the client hold the cane in the hand opposite the affected leg.

Explain the safety and body mechanics underlying using the cane on the strong side

6 Have the client push himself up from the sitting position while pushing down on the bed with his arms

7 Have the client stand at the bedside for a few minutes8 Assess the height of the cane

With the cane placed 6 inches ahead of the client’s body, the top of the cane should be at wrist level with the arm bent 25% to 30% at the elbow

9 Walk to the side and slightly behind the client, holding the gait belt if needed for stabilityTHE CANE GAIT

10 Move the cane and the weaker leg forward at the same time for the same distance

Place weight on the weaker leg and the cane Move the strong leg forward Place weight on the strong leg

b.1 SITTING WITH A CANE 5 4 3 2 1 REMARKPROCEDURE

1Have client turn around and back up to the chair.

Have the client grasp the arm of the chair with the free hand and lower self into the chair

Bes sure to place the cane out of the way but within reach

2Set realistic goals and opportunities for progressive ambulation using a cane

3Consult with a physical therapist for clients learning to walk with a cane

4 Wash hands

5Document procedure and the client’s condition during the procedure

c. WALKING WITH A WALKERPROCEDURE

1 Identify the client, introduce self and explain the procedure

2 Lower the height of the bed3 Dangle the client at the side of the bed for several

minutes. Assess the vertigo4 Provide a robe or other covering and shoes with firm,

nonslip soles5 Assess client for strength, mobility, range of motion,

visual acuity, perceptual difficulties, and balance6 Apply gait belt around the client’s waist if balance and

stability are unreliable7 Place the walker in front of the client8 Have the client push himself up from the sitting

position while pushing down on the bed with his arms9 Have the client transfer his hands to the walker

handgrips, one at a time10 Be sure the walker is adjusted so the handgrips are

just below waist level and the client’s arms are slightly bent at the elbow

11 Walk to the side and slightly behind the client, holding the gait belt if needed for stability

WALKER GAIT 5 4 3 2 1 REMARKPROCEDURE

Move the walker and the weaker leg forward at the same time

Place as much weight as possible or as allowed on the walker leg, using the arms for supporting the rest of the weight

Move the strong leg forward and shift the weight to the strong leg

c.1 SITTING WITH A WALKER Have the client turn around in front of the chair

and back up until the back of the legs touch the chair

Have him place his hands on the chair armrests, one hand at a time

Then lower self into the chair using the arm rests for support

Set realistic goals and opportunities for progressive ambulation using a walker

Consult with a physical therapist Document procedure and the client’s condition

during the procedure Wash hands





ASSISTING CLIENT DURING MEAL TIME

PROCEDURE 5 4 3 2 1 REMARK

1Before bringing the meal tray into the room, ask whether the client needs to void or have a bowel movement

2Provide hygiene measures before serving the meal trayPosition the client in a comfortable position, preferably in a chair, if not contraindicated

3Ask about the client’s eating habits and the foods the client prefers to eat first

4 Ask what need is needed

5Make sure the foods are being served at the correct temperature

6Provide assistance if the client is unable to handle eating utensils or open containers and packages

7Provide adequate time for the client who has difficulty in chewing or swallowing.

Make sure that someone is in the room while the client is eating

8Document the type and amount of food taken at each meal

9Remove the tray after the meal and provide hygiene measures



checkist for ncm 100 (skills) (2)

Documents

wet hair

style hair

hair strands

hair ends

eye document

eye glasses

dry towel

hair dryer comb