7.3 Prometric Checkpoints: Transfer, Ambulation, Positioning, Occupied Bed, ROM, and Urine Output
Key Takeaways
In Prometric's pivot transfer, lock the wheelchair before standing the resident, apply the gait belt over clothing so only flat fingers fit under it, brace the resident's legs, and pivot without letting the resident take steps.
When ambulating with a gait belt, walk at the resident's side and slightly behind with an arm around the back holding the belt, ask how the resident feels, and walk at least 10 steps.
Prometric's side-lying checkpoints place support behind the back, between the legs with the upper knee bent in front, under the upper arm, and under the head and neck, with the resident not lying on the lower arm.
Prometric's ROM skills use three repetitions: shoulder flexion/extension and abduction/adduction; elbow flexion/extension with wrist flexion and hyperextension; and hip and knee flexion/extension with ankle dorsiflexion and plantar flexion.
For Prometric's urinary drainage bag skill, read the graduate at eye level on a flat, protected surface, record it as urine with the time on the I&O form within ±50 mL of the nurse's measurement, and keep the bag on the bed frame below the bladder.
7.3 Prometric Checkpoints: Transfer, Ambulation, Positioning, Occupied Bed, ROM, and Urine Output
This section follows Prometric's Alabama checklist for its mobility, positioning, linen, range of motion, and output skills. Every skill also carries the Indirect Care checkpoints from Section 7.1, and Credentia's versions are in Section 7.5. These procedures test the candidate's physical competence in managing resident mobility, preventing pressure injuries, maintaining skin integrity, preserving joint mobility, and recording quantitative clinical data.
1. Transfer from Bed to Wheelchair Using a Transfer/Gait Belt
Transferring a partially dependent resident from a bed to a wheelchair requires rigorous adherence to biomechanical and mechanical safety standards.
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| Gait Belt Transfer Critical Sequence Checklist |
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| 1. Position wheelchair next to bed at head of bed (45° angle or parallel)|
| 2. LOCK WHEELCHAIR BRAKES; fold footrests UP and swing out of way |
| 3. Ensure bed is in LOWEST position; LOCK BED BRAKES |
| 4. Assist resident to dangling seated position; feet FLAT on floor |
| 5. Apply NON-SKID FOOTWEAR (shoes or grip socks) |
| 6. Apply gait belt snugly over clothing (two-finger check; buckle side) |
| 7. Brace resident's knees/feet with caregiver knees/feet |
| 8. Grasp belt with UNDERHAND GRIP (palms up); count "1, 2, 3" to stand |
| 9. Pivot toward wheelchair; lower gently; hips back against seat |
| 10. Remove belt; fold down footrests; place call light in reach |
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Critical Testing Steps and Checkpoints
- Wheelchair and Bed Positioning: Place the wheelchair near the bed before helping the resident sit up, positioned so the front interior wheel is close enough to the bed for a pivot. Move the footrests out of the way (lift, swing, or remove them). Lock the wheelchair before standing the resident.
- Bed Safety and Footwear: Put nonskid footwear on the resident before standing. Help the resident sit on the side of the bed without pulling on the lower arms or hands, give the resident time to adjust to sitting, and place both feet flat on the floor. Watch for dizziness.
- Gait Belt Application: Place the gait belt snugly around the resident's natural waistline over their clothing (never on bare skin). Fasten the buckle securely. Prometric's checkpoint is that only flat fingers or a flat hand fit under the belt and the belt does not catch skin or skin folds. Position the buckle slightly off-center (toward the hip) to avoid pressure on the spine or sternum.
- Caregiver Stance and Grip: Stand in front of the resident with a wide base of support, reaching under the resident's arms to hold the belt at the sides or around the back throughout the transfer (an underhand grip is secure). Brace one or both of the resident's legs with your knees or feet while the resident stands, turns, and sits.
- Stand, Pivot, and Seat: Signal the resident by counting "1, 2, 3." On three, straighten your legs smoothly while keeping your back straight. Assist the resident to a standing position. Pivot toward the wheelchair without having the resident take steps (Prometric's resident can stand but cannot step) until the backs of the resident's legs touch the seat. Lower the resident gently in a controlled way so the hips end up against the back of the seat.
- Post-Transfer Adjustments: Leave the resident in good body alignment with hips against the back of the seat and feet on the footrests, then remove the belt without pulling or hurting the resident. Place the call light within reach.
Ambulate the Resident Using a Transfer/Gait Belt
Prometric's ambulation skill uses a resident who needs some help to stand and walk.
- Apply the belt over clothing before standing the resident, snug enough that only flat fingers fit under it.
- Give a cue or signal before helping the resident stand, and hold the belt without gripping it only at the front or only at the nearest side.
- Ask how the resident feels after standing and again while walking.
- Walk at the resident's side and slightly behind, with an arm around the resident's back holding the belt.
- Walk at least 10 steps, then help the resident turn so the backs of the legs touch the chair seat, and support the resident while sitting.
- Remove the belt without harming the resident, leave the resident aligned with hips against the back of the chair, and use good body mechanics throughout.
2. Change Resident's Position to Supported Side-Lying (Lateral) Position
The supported lateral (side-lying) position relieves pressure on the sacrum, heels, and greater trochanters, preventing Stage 1 to Stage 4 pressure injuries in bedbound residents.
The Four Critical Supportive Pillows
Prometric's checklist looks for support in four places. First turn the resident onto the side, then place the positioning devices, keeping the resident a safe distance from the edge of the bed:
- Back Support Pillow: Fold or roll a pillow lengthwise and tuck it firmly behind the resident's back, gently easing them back against it to maintain a 30-degree lateral tilt without rolling flat.
- Knee and Ankle Pillow: Place a pillow lengthwise between the resident's legs from above the knees down to the ankles. The upper knee and hip must be flexed forward, and the pillow must prevent the medial condyles of the knees and the medial malleoli of the ankles from touching.
- Upper Arm Support Pillow: Place a pillow beneath the dependent upper arm and wrist, resting the arm comfortably in front of the chest to maintain thoracic expansion and prevent shoulder strain.
- Head and Neck Pillow: Adjust the pillow beneath the resident's head so that the cervical spine remains straight and aligned with the thoracic spine, ensuring the ear is not folded.
Bed Height and Safety Sequence
- Raise bed to working height before turning.
- Prometric does not grade side rail use, but if the bed has rails, raising the rail on the side the resident turns toward adds safety (Credentia's checklist requires it).
- Make sure the resident is not lying on the lower shoulder, arm, or hand, and that the upper knee is bent in front of the lower leg.
- Cross the resident's arms over their chest and cross the near ankle over the far ankle.
- Place one hand on the resident's shoulder and the other on the resident's hip; roll the resident smoothly onto their side.
- After pillow placement, lower the bed to its lowest position, position the call light in hand, and perform hand hygiene.
3. Change Bed Linen with Resident in Bed (Occupied Bed)
Changing an occupied bed requires systematic technique to replace soiled linens without exposing the resident to falls, skin friction, or contamination. Prometric's checklist looks for these points: keep the resident a safe distance from the edge; remove and replace the bottom sheet on one side before turning the resident to the other side; keep the resident on a bottom sheet throughout; secure the bottom sheet (a fitted sheet over all four corners, or a flat sheet tucked at the head and sides) with no creases or folds; turn the resident without pulling sheets in a way that causes friction or shear; replace the top sheet with a clean one, tucked loosely under the foot of the mattress so it does not press on the toes and covering the resident to the shoulders without tucking the sides; keep the pillow under the head except briefly while changing the pillowcase; and finish with the resident between the top and bottom sheets and soiled linens in the hamper.
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| Occupied Bed Linen Change Procedure Sequence |
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| 1. Provide privacy; raise bed to comfortable working height |
| 2. Cover resident with clean bath blanket; loosen and remove soiled sheet|
| 3. Ensure opposite side rail is UP; roll resident to opposite side |
| 4. Loosen soiled bottom linen; ROLL SOILED LINEN INWARD TO BACK |
| 5. Apply clean fitted sheet & draw sheet; TUCK ROLL UNDER SOILED ROLL |
| 6. Raise side rail; move to other side; lower working side rail |
| 7. Roll resident over clean roll onto clean side |
| 8. Remove soiled linen into hamper WITHOUT SHAKING |
| 9. Pull clean linen taut (NO WRINKLES); tuck corners securely |
| 10. Turn supine; apply top sheet & blanket; CREATE TOE PLEAT |
| 11. Lower bed to lowest position; place call light in hand |
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Critical Testing Steps and Checkpoints
- Modesty Draping: Place a clean bath blanket or top sheet over the resident before removing the soiled top sheet, ensuring the resident is never exposed.
- Rolling Inward: When stripping bottom linens, roll the soiled bottom sheet and draw sheet soiled side inward toward the resident's back, creating a compact longitudinal roll tucked tightly against their spine.
- Clean Linen Placement: Fanfold the clean bottom sheet and draw sheet lengthwise, tucking the clean roll underneath the soiled roll.
- Rolling Over the Linen Roll: Ensure the side rail is raised before instructing the resident to roll over the linen hump onto the clean side. Move to the opposite side of the bed.
- Linen Disposal Without Shaking: Loosen the soiled linens, roll them into a bundle, and place them immediately into the laundry hamper. Never shake or fluff linens (which aerosolizes pathogens and lint), and never allow soiled linens to touch the floor or uniform.
- Wrinkle-Free Tautness: Pull the clean sheets completely taut to eliminate wrinkles. Mattress wrinkles exert localized friction and pressure, accelerating skin shear and pressure injury formation.
- The Toe Pleat: After applying the clean top sheet and blanket, tuck the bottom edge beneath the foot of the mattress and create mitered corners. Loosen the linens over the resident's feet by grasping the covers and pulling upward 2 to 3 inches to form a toe pleat. A toe pleat relieves downward tension on the feet, preventing decubitus ulcers on the dorsal toes and preventing permanent footdrop contractures.
4. Passive Range of Motion (PROM) Exercises
Passive Range of Motion (PROM) maintains joint flexibility, stimulates synovial fluid circulation, and prevents irreversible joint contractures in immobilized residents.
Prometric PROM Rules
- Two-Handed Joint Support: Always support the extremity with two hands: place one hand above the joint and one hand below the joint (e.g., when exercising the elbow, support the upper arm with one hand and the wrist with the other). Never allow an unsupported joint to dangle.
- Slow, Gentle Motion: Move the joint smoothly, slowly, and gently through its natural physiological range of motion. Never force a joint beyond the point of resistance or pain.
- Repetitions: Prometric's instructions call for three repetitions of each exercise, on the side named on your instruction card. Exercise only the correct joints on the correct side.
- Pain Inquiry: Instruct the resident to verbalize immediately if they experience discomfort: "Please let me know if you feel any pain or tightness." If the resident reports pain or grimaces, stop the movement immediately and report the pain to the nurse.
Motions Prometric Evaluates
| Joint / Extremity | Specific Movements Evaluated | Anatomical Execution Protocol |
|---|---|---|
| Shoulder | Flexion & Extension; Abduction & Adduction | Flexion: Raise the straightened arm forward and upward toward the head of the bed; Extension: Return the arm downward to the side of the body; Abduction: Move the straightened arm outward away from the side of the body; Adduction: Return the arm inward toward the midline of the body. |
| Elbow & Wrist | Elbow Flexion & Extension; Wrist Flexion & Hyperextension | Elbow Flexion: Bend the arm at the elbow; Elbow Extension: Straighten it; Wrist Flexion: Bend the wrist to move the hand down; Wrist Hyperextension: Bend the wrist to move the hand back. Pronation and supination are not part of Prometric's elbow and wrist skill. |
| Hip, Knee & Ankle | Hip and Knee Flexion & Extension; Ankle Dorsiflexion & Plantar Flexion | Hip/Knee Flexion: Supporting under the knee and ankle, bend the knee and hip, raising the leg toward the torso; Extension: Return the leg to the mattress, supporting it so the heel does not rub the sheet; Dorsiflexion: Move the foot up toward the head; Plantar Flexion: Point the foot down toward the mattress. Hip abduction is not part of Prometric's skill. |
5. Emptying Urinary Drainage Bag and Measuring/Recording Output
Accurate measurement of urinary output is essential for evaluating kidney function and fluid balance. Prometric's skill is "Empty contents of resident's urinary drainage bag, and measure and record urine output on an Intake and Output (I&O) form." Wear gloves whenever you handle the bag, the graduate, or urine, and remove them before you write on the I&O form.
Step-by-Step Testing Protocol
- Infection Control Setup: Don clean gloves. Obtain a clean paper towel barrier and a calibrated measuring container (graduate).
- Floor Barrier: Place the clean paper towel barrier directly on the floor beneath the urinary drainage bag. Place the calibrated graduate upright on the barrier.
- Draining Without Contamination: Open the drain valve/clamp on the drainage bag spout. Direct the urine stream into the graduate. The drain spout must NEVER touch the rim, inside walls, or liquid level of the measuring container. Touching the container contaminates the closed urinary drainage system.
- Closing and Protecting the Drain: Empty the full contents of the bag. Close the drain clamp and tuck the drain into its protective holder or pocket (wipe it with an alcohol pad first only if your facility's procedure calls for it). Leave the bag hanging from the bed frame, not the side rail, with the bag and tubing off the floor and the bag below the bladder throughout.
- Eye-Level Volumetric Reading: Pick up the graduate. Place a fresh paper towel barrier on a flat, solid, level horizontal surface (such as an overbed table or bathroom counter). Place the graduate on the barrier. Bend down to read the fluid level (meniscus) at EXACT EYE LEVEL. Reading while holding the graduate in the air or looking down from above produces severe parallax errors.
- Disposal and Cleanup: Empty urine into the toilet. Flush toilet. Rinse graduate with water, pour rinse water into toilet, and dry container. Discard barriers and gloves. Perform hand hygiene.
- Documentation: Record the output immediately on the official candidate recording sheet in milliliters (mL) or cubic centimeters (cc).
Evaluator Tolerance Margin
Prometric requires the recorded output to be within ±50 mL (cc) of the nurse's measurement, recorded as urine with the correct time on the I&O form, written with clean hands. (Credentia's urinary output skill is different: it measures urine poured from a bedpan and uses a ±25 mL tolerance; see Section 7.5.)
When transferring a resident from the bed to a wheelchair using a gait belt, what grip technique and body mechanics must the Certified Nursing Assistant use?
Grasp the belt from above with an overhand grip and twist at the waist while lifting the resident
Hold the belt with an underhand grip, brace the resident's knees, and lift with the legs
Pull the resident up by the underarms while loosening the gait belt so it does not dig into the skin
Have the resident wrap both arms tightly around the CNA's neck and pull upward on the count of three
During an occupied bed change, why must the CNA create a mitered corner with a toe pleat at the foot of the bed?
To make the bed linens completely rigid so they cannot move during the night
To relieve pressure on the feet, which helps prevent pressure injuries and footdrop
To keep the resident from rolling out of bed while the aide is repositioning the resident
To keep the mattress firmly anchored against the bed frame when the head of the bed is raised
After draining a resident's urinary drainage bag into a calibrated graduate, which procedure must the candidate follow to measure and document the output correctly according to Prometric testing criteria?
Set the container on the floor, look down at it from above, and record the nearest marked line
Lift the container up into the air while standing and estimate the volume to the nearest 100 mL
Pour the urine directly into the sink and record an estimate based on the markings printed on the bag
Read it at eye level on a protected flat surface and record it as urine with the time, within ±50 mL
Sections you finish are checked off in the contents.