7.2 Step-by-Step Walkthrough of High-Frequency Skills

Step-by-Step Walkthrough of High-Frequency Skills

Every skill below is wrapped in the indirect-care steps from Section 7.1 (knock, introduce, wash hands, explain, privacy … call light in reach, bed low and locked, wash again). The numbered lists show the direct-care steps unique to each skill, and each one ends with the single fail point evaluators cite most often.

1. Handwashing (the skill you should assume you will get)

1. Turn on water and wet hands and wrists with fingertips pointing down so water runs from clean to dirty.
2. Apply soap and lather; rub all surfaces — palms, backs, between fingers, and under the nails — with friction for at least 20 seconds (about singing 'Happy Birthday' twice).
3. Rinse with fingertips still pointing down.
4. Dry hands with a clean, dry paper towel, then use a fresh, dry towel to turn off the faucet.
5. Dispose of towels without touching the wastebasket rim.

Fail point: turning off the faucet with a bare hand (recontaminating clean hands) or lathering under 20 seconds.

2. Counting & Recording Radial Pulse and Respirations

1. Place your middle and index fingertips (never your thumb) on the radial artery at the thumb side of the wrist.
2. Count the pulse for one full minute; note rate, rhythm, and force. Record it.
3. Without telling the resident, keep your fingers in place and count respirations for one full minute (one rise + fall = one breath).
4. Record both values and report to the nurse.

Fail point: using your thumb (you feel your own pulse) or letting the resident know you are counting breaths (they change their breathing). Your count must be within 5 of the evaluator's.

3. Measuring & Recording Blood Pressure (manual)

1. Position the resident with the arm supported at heart level, palm up; bare the upper arm.
2. Apply a correctly sized cuff 1 inch above the antecubital (elbow) bend, over the brachial artery.
3. Locate the brachial pulse, place the stethoscope over it, and close the valve.
4. Inflate ~30 mmHg above where the pulse disappears, then deflate slowly (2–3 mmHg/sec).
5. Note systolic at the first Korotkoff sound and diastolic at the last sound; record as systolic/diastolic (e.g., 132/84 mmHg).

Fail point: a reading more than 4 mmHg off the evaluator's, or wrapping the cuff over clothing. If sounds are unclear, fully deflate and wait 1–2 minutes before retrying — never re-inflate immediately.

4. Measuring & Recording Urinary Output

1. Put on gloves.
2. Pour urine from the bedpan/urinal or empty the catheter bag's spout into a graduate (measuring container) without letting the spout touch the container.
3. Place the graduate on a flat surface and read the volume at eye level.
4. Record the amount in mL/cc, empty and clean the graduate, remove gloves, and wash hands.

Fail point: reading the graduate while holding it in the air (inaccurate) or letting the drain spout touch the container (introduces bacteria / CAUTI risk).

5. Transfer Bed-to-Wheelchair with a Gait Belt

1. Lock the bed and place the wheelchair at a 45° angle on the resident's STRONG (unaffected) side; lock the wheelchair brakes and swing/raise the footrests up.
2. Lower the bed so the resident's feet are flat on the floor; apply non-skid footwear.
3. Assist to a sitting position and let the resident dangle briefly to prevent dizziness.
4. Apply the gait belt over clothing, snug — you should fit two fingers underneath.
5. Grip the belt from underneath with both hands, brace the resident's knees, count '1-2-3,' and help them stand and pivot toward the stronger side into the chair.
6. Lower them gently, reposition, lower footrests, and place the call light within reach.

Fail point: unlocked brakes, footrests left down, or transferring toward the weak side — any of these is a critical safety fail.

6. Assisting with Ambulation Using a Gait Belt

1. Apply non-skid footwear and a snug gait belt over clothing.
2. Help the resident to standing; let them steady themselves.
3. Stand slightly behind and to the weaker side, grasping the belt underhand.
4. Walk at the resident's pace, encouraging normal arm swing.
5. If the resident starts to faint/fall, do NOT hold them up — use the belt to ease them to the floor, bending your knees and protecting their head.

Fail point: trying to hold a falling resident upright (injures both) instead of using the belt to control the descent; or ambulating a fall-risk resident without the belt.

7. Perineal Care (female)

1. Gloves on; drape for privacy and expose only the perineum.
2. With warm water and a washcloth, clean from front (urethra) to back (anus), using a clean section of cloth for each stroke.
3. Clean the labia, then the center, then dry the area front to back.
4. Reposition, remove gloves, wash hands.

Fail point: wiping back to front or reusing the same soiled surface — both push bacteria toward the urethra and cause a critical fail.

8. Passive Range of Motion (one joint, e.g., shoulder)

1. Support the limb above and below the joint with your hands/palms.
2. Move the joint slowly and smoothly through its motions (e.g., flexion, extension, abduction, adduction).
3. Move only to the point of resistance or mild discomfort — stop, never force.
4. Repeat the ordered number of times (usually 3–5), watching the resident's face for pain.

Fail point: forcing the joint past resistance or into pain, or failing to support both sides of the joint.

9. Applying an Anti-Embolism / Elastic (TED) Stocking

1. With the resident lying down (recumbent) and the leg elevated, turn the stocking inside-out to the heel.
2. Slip it over the toes and heel first, aligning the heel pocket.
3. Unroll/smooth it up the leg from ankle toward the knee/thigh.
4. Ensure it is wrinkle-free and the toe opening (if any) sits correctly.

Fail point: applying it with the resident sitting/standing, or leaving wrinkles — folds create pressure points and defeat the stocking's purpose.

10. Indwelling (Foley) Catheter Care & Dressing the Affected Arm

Catheter care: gloves on; hold the catheter near the meatus to avoid tension; clean from the urethral meatus outward (away from the body) using a fresh wipe for each stroke; secure tubing to prevent pulling. Fail point: cleaning toward the body (pushes organisms in — CAUTI).

Dressing a resident with a weak/affected arm: support the arm; put the garment on the weak (affected) arm FIRST, then the strong arm; to undress, remove the strong arm first. Remember 'weak in, strong out.' Fail point: dressing the strong side first, which forces painful stretching of the weak limb.

Quick reference: accuracy tolerances