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Licensed to: iChapters User
Clinical Skills for Enrolled/Division 2 Nurses
© 2009 Cengage Learning Australia Pty Limited
1st Edition
Joanne Tollefson
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Title: Clinical skills for enrolled division 2 nurses / Joanne
Tollefson ... [et al.]
Edition: 1st ed.
ISBN: 9780170180924 (pbk.)
Notes: Includes index.
Subjects: Nursing. Clinical competence.
Other Authors/Contributors: Tollefson, Joanne.
Dewey Number: 610.730994
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Part 1
General Care
Ambulating the patient
Elimination – patient care
Handwashing
Pain management (non-pharmacological
interventions – dry heat and cold)
Patient education
Personal hygiene – bed bath or assisted shower
Personal hygiene – mouth care, shaving, hair care and nail care
Positioning of a dependent patient
Range of motion exercises
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Clinical skills competency
CRITERIA:
Y=Satisfactory
S=Requires Supervision
DEMONSTRATES: The ability to effectively and safely D=Requires Development
assist a patient to ambulate
COMPETENCY: Ambulating the patient
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled
Nurse, 2002)
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Identifies safety considerations (6.1, 8.1)
3. Gathers equipment (7.1, 7.4, 8.1)
– assistive devices
4. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure
(2.1, 3.1, 3.2, 3.4, 7.1, 8.2, 8.3, 8.4)
5. Washes hands (7.1, 8.1)
6. Assists the patient to walk (6.1, 7.1, 8.1, 8.2)
7. Documents and reports relevant information (1.1,
1.3, 1.4, 1.5, 7.1, 7.3, 8.1, 8.2)
8. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE:__________________________________
2
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Clinical Skills for Enrolled/Division 2 Nurses
3
Clinical skills competency
Linking theory to practice
COMPETENCY: Assisting the patient to ambulate
Identifying indications – Patients who require assistance to ambulate are those suffering from weakness or
frailty resulting from bed rest for a few days or more protracted time periods, or those who are debilitated
from illness. Assisting the post-operative patient to ambulate is the most effective nursing measure to
prevent post-operative complications. Patients who have had cerebrovascular accidents, paralysis,
brain damage, an amputation or some musculoskeletal disorders, such as total hip replacement, require
specialised assistance to ambulate. This is usually provided by a physiotherapist or a nurse with specialised
knowledge. For any patient who has been immobilised, regaining the ability to walk is a morale boost.
Prolonged immobility can have severe consequences for the patient. These consequences include the
following:
•
•
•
•
•
•
•
•
constipation
urinary retention
altered tissue perfusion
decubitus ulcer
hypostatic pneumonia
osteoporosis
renal calculi
deep vein thrombosis.
Identifying safety considerations – Assessment of the patient who has been immobile is required before
attempting to assist them to walk. Consult the patient’s care plan for particular instructions. Activity
tolerance, strength, orthostatic hypotension, pain, coordination and balance should be taken into
consideration. Before the patient is able to ambulate, a preparation program must be carried out and
the patient’s ability assessed. This may take a few minutes or may be undertaken over a number of days.
A preparation program is outlined below:
• Muscle strength and range of motion is encouraged with gradual progression to active range of
motion and isometric exercises through to resistance exercises.
• The patient’s sitting balance is encouraged by initially positioning them in an upright position,
assisting them to ‘dangle’ at the edge of the bed with their feet supported on stool. This is
practised until there is no dizziness or swaying noticed or reported.
• Standing balance is encouraged. The patient is assisted to stand at the bedside and gradually to
stand unassisted by either the nurse or by hanging onto the bed. Standing balance is attained
when the patient is able to keep the trunk still and move their extremities without swaying.
• Weight-shifting, where the patient is able to move their weight from one leg to the other or
from one side of their body to the other without losing balance, is the next goal.
The patient may require anti-embolism stockings (TEDs) to be applied before ambulating. The nurse must
remain close to the patient who is ambulating. Rest periods need to be scheduled because ambulation
is an increase in activity and the patient will be fatigued. Initial exercise and ambulation periods should
be short then gradually increased as the patient can tolerate them. Environmental factors also require
consideration. The floor must be dry and should be free of clutter, such as electrical cords, scatter rugs,
magazines and newspapers. Handrails give the patient a sense of security. The patient should be wearing
shoes that fit well, give good support and have non-skid soles. Medical equipment (IV tubing, urinary
catheters, chest drains or wound drains) will require consideration to assist the patient to get out of bed
and walk without constraint. IV poles with wheels and cloth bags to carry urinary catheters or drainage
apparatus can be used to increase mobility.
The nurse must also assess their own strength and ability. If unsure, recruit another nurse to assist. This is
an occupational health and safety issue as well as a patient safety measure. Assistive devices (as outlined
below) should be available for the patient’s use as necessary. If the patient requires specific aids such as
crutches or various types of walker, a training program should be carried out by a physiotherapist or nurse
with specialised knowledge or experience.
Assistive devices that may be needed:
Safety/walking belt is a belt that the patient wears snugly around the waist. The nurse walks
beside the patient, grasping the belt in the middle of the back and the side. If the patient
becomes dizzy or loses their balance, the nurse is able to support them with the belt.
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4
Clinical Skills for Enrolled/Division 2 Nurses
Canes provide extra stability for patients who have one weak leg but are still able to bear
weight on both legs. They also promote a feeling of security. The tip of the cane should have
a non-skid rubber surface for safety. The top curve (hand grip) is held in line with the hip
joint of the unaffected leg, with the patient’s elbow slightly flexed. The affected leg and cane
are moved forward simultaneously while the unaffected leg bears the weight. The affected
leg and cane then take the weight while the unaffected leg is moved forward.
Walkers provide four points of support thus giving a wide base and are the most secure of
all of the assistive devices. The top of the standard walker is level with the hands when the
elbows are flexed between 25–30 degrees. The patient places the walker in front of them
and steps forward. Walkers are usually constructed of aluminium since they need to be
lightweight.
Crutches are used when no weight-bearing, single leg weight-bearing or modified weightbearing is allowed. The patient needs upper-body strength and arm control to use crutches.
The patient’s weight is supported by the wrists, hands and shoulders, not the axillae. Pressure
on the axillae can cause irreversible nerve damage. Crutches must be measured and fitted
by a trained professional. Different gaits are used for different types of weight-bearing. The
patient requires instruction in the type of gait to be used for his type of disability. The gait
pattern is determined by the physician or the physiotherapist and is usually taught to the
patient by that professional.
Evidence of therapeutic interaction – A clear, thorough explanation of the procedure, including distance to
be walked, assistance to be expected and instructions to alert the nurse to any fatigue or pain encountered
should be given. The patient will then be able to make an informed decision about their strength and
ability. Explanation, as always, enlists patient cooperation, and alleviates any anxieties they may have over
this adventure. Most patients are somewhat unsure about leaving the safety of their bed and venturing
out on limbs that feel very shaky. A calm, confident manner, plenty of sincere reassurance and physical
support assist the patient to take their first steps.
Handwashing is a first-line of defence against infection. Handwashing removes transient micro-organisms
from the nurse’s hands to prevent cross-infection.
Assisting the patient to walk – Progressive assistance may be needed. Initially assist the patient by using a
walking or safety belt. The patient is supported until they gain confidence. The walking belt prevents injury
if the patient loses balance. When the patient is competent and confident walking with the safety belt, the
belt can be removed. Walking with the nurse is the next step as this allows for support of the patient if they
lose their balance or feel weak. Assist the weak or dizzy patient to the nearest chair or bed, or if necessary
to the floor.
Documentation of ambulation should include distance walked, assistance required and patient response
to ambulation (including falling episodes).
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following bibliography has been used to compile
the information. The student is expected to have learned the material surrounding this skill as
presented in the bibliography that follows. No single reference is complete on this subject.
Bibliography
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice (7th ed.).
Upper Saddle River, NJ: Prentice-Hall.
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Clinical skills competency
COMPETENCY: Elimination – patient care
DEMONSTRATES: The ability to effectively and safely
assist the patient with their elimination needs
CRITERIA:
Y=Satisfactory
S=Requires Supervision
D=Requires Development
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled Nurse,
2002)
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Performs routine urinalysis (6.1, 7.1)
3. Assesses patient’s ability to be independent (6.1, 7.1, 8.1)
4. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure,
discusses rationale for remaining in bed (2.1, 3.1, 3.2, 3.4, 8.2)
5. Gathers equipment (7.1, 7.4)
– commode, bedpan, urinal as required
– coversheets, clean gloves
– toilet paper, waterproof sheet, air freshener
– handwashing equipment
– urinalysis equipment
– perineal care equipment (basin, soap, water,
washer, towel)
– relevant personal protective equipment
6. Displays problem-solving abilities; e.g. positions
patient appropriately, provides privacy, provides
equipment for handwashing (2.1, 3.8)
7. Washes hands (7.1, 8.1)
8. Assists the patient to use the commode (1.3, 1.4, 7.1, 8.1)
9. Gives and receives a urinal (1.3, 1.4, 7.1, 8.1)
10. Gives and receives a bedpan (1.3, 1.4, 7.1)
11. Perineal care (1.3, 1.4, 7.1)
12. Disposes of excreta (1.3, 1.4, 7.1, 8.1)
13. Cleans, replaces and disposes of equipment
appropriately (8.1, 9.2, 10.2)
14. Carries out urinalysis if required (6.1, 8.1)
15. Documents and reports relevant information (1.1, 1.3,
1.4, 1.5, 6.1, 7.3, 8.1)
16. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
5
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6
Clinical Skills for Enrolled/Division 2 Nurses
Clinical skills competency
Linking theory to practice
COMPETENCY: Assisting with elimination
The indication for use of elimination-assisting devices (commode, bedpan, urinal) is the inability to
mobilise due to the condition the patient has or as part of the treatment they are undergoing. Physicians
may order the patient to be maintained on bed rest ‘with Toilet Privileges’ in which case, the patient can
use the toilet with as much assistance getting there as necessary. If the physician orders ‘Commode’ then
the patient is confined to the use of the commode whether or not they are able to physically mobilise. ‘Bed
Rest’ means the use of a urinal or bedpan for elimination. Nurses can initiate the use of any of the assistive
devices if they believe it will assist the patient. Commodes, urinals and bedpans provide a receptacle for
elimination of wastes for the bedbound patient, a means of obtaining a specimen of waste for analysis and
a means to obtain an accurate measurement of the patient’s output.
Perineal care is cleansing of the perineal area – a hygiene and a comfort measure. It is done during the
daily bath as well as any time it is necessary due to soiling during elimination or incontinent episodes. The
perineal area, if left soiled, will macerate and skin integrity will be lost, leading to possible infection and
certainly discomfort for the patient.
Urinalysis is the analysis of the urine of the patient to determine their health status. Many medical
conditions and fluid volume alterations manifest in the urine and a simple examination will reveal many
abnormalities.
Assessing patient’s ability to be independent is what the choice of assistive devices will be based on. If the
patient is able to ambulate with assistance, taking them to the toilet would be the best option as it is less
psychologically unsettling than having to stay in bed even to accomplish the most basic of needs. If the
patient is able to transfer, but unable to be mobilised, a commode is the next best choice. It is similar to a
toilet, out of the bed and less distressing for most patients to use. Urinals and bedpans are usually used in
the bed, although some male patients are able to stand at the bedside to use the urinal.
Therapeutic interactions for this simple nursing measure are often very important. Accomplishing these
basic elimination needs is a matter of intense privacy for most people and the cultural mores surrounding
elimination are rigid. For example, most of us were very well ‘toilet trained’ by the age of two or so,
and were taught that elimination required privacy. Adults are expected to meet their own elimination
needs without assistance and thus feel like they are regressing when help is needed. Constipation from
suppression of the urge to defecate is a possible outcome with some patients (Richmond & Wright,
2005). Reinforcement of the reasons why the bedpan or urinal is necessary will help to reduce feelings of
inadequacy. Tact and consideration are needed so the patient’s embarrassment about sights, sounds and
odours is not heightened.
Displaying problem-solving abilities to give patients maximum comfort during elimination usually means
positioning them as close to the usual anatomical position assumed for toileting as possible. The patient’s
condition and restrictions will determine this. Take care that the contents of the bedpan or urinal are
not spilled during removal of the bedpan/urinal. Toilet paper, air freshener and handwashing equipment
should be in easy reach for the patients to assist themselves if they are capable. Wear clean gloves for
protection against body fluids, especially in removal of a urinal and/or bedpan.
Gathering equipment as a time-management strategy. The efficient accomplishment of this procedure
reduces the patient’s discomfort and embarrassment.
A commode is a wheeled armchair with a toilet seat and a receptacle below the seat for collection of urine
and faeces. Some commodes have a second plain seat that is closed to transform the commode into a
chair. Some commodes are built to be wheeled over a toilet, so the patient is seated on the commode and
wheeled to the toilet – this involves one transfer only. Commodes have locks on their wheels to prevent
slippage during transfer of the patient onto the commode.
Bedpans are used for faecal elimination in both male and female patients and for urinary elimination for
most female patients. Bedpans are commonly available in two types: the regular pan and the fracture or
slipper pan, which is smaller and flatter for those patients who have physical limitations or are unable to
lift their buttocks onto the regular bedpan. Bedpans should never be placed on the floor, the overbed table
or the patient’s locker for hygienic reasons. Swirling with warm water and emptying during cold weather
should warm metal bedpans – cold metal against skin will reduce the urge to void or defecate.
Urinals are deep narrow receptacles for urine. They are mostly used by male patients. There are female
urinals available, but these have proved to be very difficult for most women to use. Urinals, too, should
never be placed on the floor, the overbed table or the patient’s locker for hygienic reasons.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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Clinical Skills for Enrolled/Division 2 Nurses
7
Toilet paper must be available for cleansing the perineum after urinary or faecal elimination.
Covers for the bedpan and urinal are used during transport of the used bedpan/urinal to the utility room
for disposal. They are more aesthetically pleasing than an open pan or urinal.
A waterproof sheet or bluey is placed under the bedpan to catch any inadvertent spills so the linen is not
soiled.
Clean gloves are worn for personal protection during possible contact with bodily fluids.
Handwashing equipment should be available: a wet, warm washer and towel for cleansing hands following
elimination.
An air freshener eliminates odours to reduce embarrassment.
Perineal care equipment includes a basin of warm water, towel, washer, soap, clean gloves, bath blanket and
ointment if needed.
Urine-testing equipment if required – test tube, urine-testing reagent strips, urinometer, paper towel and
gloves.
Personal protective equipment (PPE) – relevant PPE is gathered for each procedure and standard precautions
are followed to handle body secretions and excretions.
Assisting patient to use a commode – The patient is assisted out of bed and onto the commode. If the
patient is able, leave them in privacy for a few minutes – leave the call bell in their hands. The patient may
or may not need assistance to clean the perineal area. If assistance is needed, help the patient to stand and
lean against the bed. Wrap toilet paper around your gloved hand and wipe the perineal area from the pubic
area backwards to the anal area in women, and from behind the scrotum in men so that faecal material
is not brought forward to the urinary (or vaginal) meatus. If wiping with dry paper is not sufficient to
cleanse the area, assist the patient to return to bed and do perineal care (see below). Provide the patient
with handwashing equipment to prevent the spread of micro-organisms. Use air freshener if there are no
contraindications (patients with respiratory difficulties may react adversely to the aerosolised particles;
the perfume in some fresheners is offensive to some patients) to eliminate embarrassing odours. Remove
the commode from the room for cleansing.
Giving and receiving a urinal – Assist the patient to stand at the bedside if health permits, or to a semiupright position. Most patients are able to position the urinal independently. If not, place the urinal
between the patient’s legs with the handle upward. The penis may need to be picked up and placed in the
urinal neck. Leave the patient in privacy and with the call bell in hand. Return when called or in about
three to five minutes. Remove the urinal and cover. Wipe the tip of the penis to remove any urine. Make
sure the perineum is dry (may require perineal care). Offer handwashing equipment. Take the covered
urinal to the utility room.
Giving and receiving a bedpan – Place the warmed bedpan on the end of the bed or on an adjacent chair.
Fold the covers down to expose the hip and adjust the gown so it will not be soiled. Assist the patient to
raise their buttocks off the bed. The supine patient should flex their knees and, resting their weight on
heels and back, raise the buttocks. The nurse assists by placing the arm/hand nearest the patient’s head
under the lower back and using the elbow as a fulcrum, and the arm as a lever, pushes upward to give
more movement to the patient’s hips. With the other hand, slip a waterproof sheet and the bedpan, with
the open end towards the feet, under the buttocks of the patient. The use of body mechanics will reduce
injuries from muscle strain in both the patient and the nurse. Make sure the smooth round end of the
bedpan is in contact with the buttocks to prevent both abrasion of the skin and spillage of the contents of
the pan. A fracture pan is placed with the flat end under the patient’s buttocks. Elevate the head of the bed
to semi-upright so the patient’s back is comfortable, and the position is close to that assumed normally. If
this position is not possible, place a small pillow under the patient’s back to increase comfort. Replace the
bed linen and side-rails and leave the patient in privacy and with the call bell in their hand. Leave the toilet
paper in reach. When the patient is finished, again, fold the covers down and ask the patient to raise their
buttocks. Remove the bedpan, leaving the waterproof sheet. The patient may or may not need assistance
to clean the perineal area. Assist the patient with any needed cleaning of the perineal area. Wrap toilet
paper around your gloved hand and wipe the perineal area from pubic area backwards to anal area in
women, and from behind the scrotum in men so that faecal material is not brought forward to the urinary
(or vaginal) meatus. Use one stroke per each piece of paper. Turn the patient on their side and spread the
buttocks to clean the anal area in the same manner. Soiled toilet paper is placed in the bedpan. Perineal
care may be required (see below). Remove the waterproof sheet. Provide equipment to clean hands. Use
air freshener as indicated. Take the covered bedpan to the treatment room.
The patient who is unable to assist should be rolled onto their side with their back towards the nurse.
Position a waterproof sheet under the buttock area. Powder may be applied lightly to the buttocks to
prevent the skin from sticking to the pan. The bedpan (usually the fracture pan) is placed against the
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8
Clinical Skills for Enrolled/Division 2 Nurses
patient’s buttocks with the open end towards the feet. Facing the head of the bed, the nurse holds the far
hip with one hand and the bedpan in place with the other. Smoothly (by transferring weight from front
to back leg) roll the patient towards you and onto their back with the bedpan in place. Proceed as for the
patient who is able to assist. Removing the bedpan entails steadying the bedpan in its horizontal position
and rolling the patient off the pan towards you for safety. Remove and cover the bedpan, place it on the
end of the bed or nearby chair. Clean the perineum and proceed as above.
If using a disposable bedpan, place a ‘bluey’ underneath in case of spillage.
Perineal care removes normal secretions and odours as well as any traces of excreta, and also prevents
infection and promotes comfort.
• Position the patient in a supine position with the bed linen folded down to the foot of the bed.
Place a towel under the hips long ways so that the lower end can be used to dry the anterior
area and the upper edge (under the patient’s buttocks) is used for the anal area.
• Females – Ask the patient to flex her legs and drape her upper body and legs with the bath
blanket to reduce embarrassing exposure. Wrap the tails of the bath blanket around the legs
to anchor the blanket and bring the middle up to expose the perineum. Wear gloves. Wash
and dry the upper inner thighs. Clean the labia majora and then spread the labia to expose
the folds and labia minora. Using the corners of the washer, cleanse from the front towards
the anus, using one stroke per corner. If the woman has a catheter, or is menstruating, use
gauze squares (one for each stroke) to remove the fluids. Rinse the area well, using the same
procedure. Inspect for any areas of excoriation (especially between labial folds), for odour,
excess secretions or any other abnormality.
• Males – Ask the patient to flex his legs and drape the upper body in a bath blanket, bringing the
tails of the bath blanket down over the legs. Expose the genital area. Wear gloves to wash and
dry the upper inner thighs. Wash and dry the penis, using firm strokes, which may prevent an
erection. If the patient is uncircumcised, retract the foreskin to expose the glans penis. Clean it
with the washcloth, dry it and replace the foreskin. Wash and dry the scrotum. Scrotal folds in
the posterior may need to be washed and dried while the patient is on his side.
• Inspect the urinary meatus in those who have an indwelling catheter (IDC) for signs of
excoriation of the orifice. Dry the perineum well.
• Both males and females – Assist the patient to turn onto their side away from the nurse.
Spread the buttocks and cleanse the anal area. Dry well. Apply any protective ointment needed.
Return the patient to a position of comfort and readjust the bedclothes.
Disposal of excreta is done in the toilet or in a hopper in the dirty utility area of the unit. The commode,
urinal or pan is covered during transport to the dirty utility as an aesthetic measure. Clean gloves are
worn for protection against bodily fluids. Bedpan covers and waterproof sheets are disposed of in the
contaminated waste receptacle. Liquids are measured (if necessary), observed for characteristics and
flushed down the toilet or hopper. Solids are observed for colour, consistency and amount, and then
flushed down the toilet or hopper. Residual excreta that stick to the pan must be removed using toilet
paper. Traces are removed using the toilet (or similar) brush that is designated for the job. The pan or
urinal is then washed and disinfected according to the facility policy, and returned to the patient’s locker
or the rack (depending on the facility). Commodes are reassembled and returned to their usual position
or the patient’s bedside (depending on facility policy). Some units have pan/urinal flushers, which are
designed to do the washing and disinfecting.
Urinalysis as a ward routine – A fresh specimen of urine is used. The collection receptacle should be clean
to prevent any changes in test results due to contamination. Clean gloves are worn.
• Characteristics are determined by observing amount, colour, clarity and odour of the urine
specimen.
• Specific gravity (SG) is the degree of concentration of the urine compared with that of an
equal volume of distilled water (standard). Check the reagent strip used in the facility. The SG
may be determined using appropriate reagent strips. If it does not appear on the reagent strip,
a urinometer or hygrometer and a test tube are used. Twenty millilitres of urine is poured into
a test tube. The urinometer or hygrometer is lowered into the tube and given a gentle spin to
keep it away from the walls of the tube. Read the scale at eye level. Read the measurement at
the base of the meniscus (scale ranges from 1.000 to 1.60g/mL with the normal range of SG
between 1.010 and 1.25g/mL).
• pH, glucose, ketone bodies, protein, bilirubin and others are determined using reagent
strips. Remove one reagent strip from the bottle and recap the bottle tightly. Generally, the
strip is immersed to below the last test area in fresh urine and withdrawn. Lightly rest the edge
of the strip on the urine container so excess flows off and does not dribble onto your hand or
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Clinical Skills for Enrolled/Division 2 Nurses
9
the test bottle during reading of the strip. Note the time the strip is dipped and, using the guide
on the bottle, read the test areas as their reaction time is reached. The usual result is negative
(other than the pH and SG) since none of the components should be in the urine of a healthy
person. Do not touch the strip to the test result guide on the bottle, as you will contaminate the
bottle.
• Note on the vital signs sheet the characteristics, SG, pH and any abnormal test results.
Documentation of bowel action is on the TPR chart or on relevant organisational charts. The documentation
of all output is required for some patients. In this case, all urinary and liquid faecal excreta will need to be
measured. Knowledge of the individual requirements is necessary. Some patients only require a daily note
in the progress sheet that indicates that their elimination is sufficient. Any abnormalities in urine or faeces
should be noted in the progress notes. Urinalysis is documented on the vital signs sheet in most facilities.
Specific gravity, colour, clarity and any abnormal findings are recorded and reported.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following reference and bibliography have
been used to compile the information. The student is expected to have learned the material
surrounding this skill as presented in the reference and bibliography that follow. No single
reference is complete on this subject.
Reference
Richmond, J. P & Wright, M. E. (2005). Development of a constipation risk assessment scale. Clinical Effectiveness in
Nursing, 9, 37–48 (accessed: http://intl.elsevierhealth.com/journals/cein on 11 July 2006).
Bibliography
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Clinical skills competency
COMPETENCY: Handwashing
DEMONSTRATES: The ability to effectively reduce the
risk of infection by handwashing
CRITERIA:
Y=Satisfactory
S=Requires Supervision
D=Requires Development
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled Nurse,
2002)
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Prepares and assesses hands (4.1, 7.1, 8.1)
3. Gathers equipment (7.1, 7.4)
– warm running water
– soap
– paper towels
4. Turns on and adjusts water flow (4.1, 7.1, 8.1)
5. Wets hands, applies soap (4.1, 7.1, 8.1)
6. Cleans under the fingernails when required (4.1, 7.1, 8.1)
7. Thoroughly washes hands (4.1, 7.1, 8.1)
8. Rinses hands (4.1, 7.1, 8.1)
9. Dries hands (4.1, 7.1, 8.1)
10. Turns off the water (4.1, 7.1, 8.1)
11. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
10
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Clinical Skills for Enrolled/Division 2 Nurses
11
Clinical skills competency
Linking theory to practice
COMPETENCY: Handwashing
Identifying indications – Handwashing is a basic infection-control method that reduces the number
of micro-organisms on the hands, which reduces the risk of transferring micro-organisms to a patient.
Handwashing reduces the risk of cross-contamination; that is, spreading micro-organisms from one patient
to another. Handwashing reduces the risk of infection among health care workers and transmission of
infectious organisms to oneself. Handwashing must occur prior to and following each incident of patient
contact, or contact with any contaminated or organic material, following use of the toilet, and prior to and
following meals. Contact with contaminated hands is a primary source of nosocomial infection.
Preparation of hands includes inspection for any lesions and removal of jewellery (rings, bracelet, watch).
These precautions protect both the nurse and the patient. Inspection for any lesions (open cuts, abrasions)
will allow the nurse to select the appropriate soap or handwashing solution and will dictate whether further
precautions – for example, gloving or non-contact (some agencies prevent nurses with open lesions from
caring for high-risk patients) – are needed. Jewellery harbours micro-organisms in its nooks and crannies,
and between the jewellery and the skin. Removing jewellery will reduce the number of micro-organisms to
be removed and provide for greater access of soap and friction to the underlying skin, as well as protecting
valuable property from damage during the course of care. A simple wedding band may be left on, but must
be moved about on the finger during washing so that soap and friction are applied to the metal and to the
underlying skin to dislodge dirt and micro-organisms. Prior to handwashing, protective clothing should
be put on as necessary so that touching hair or clothing does not later contaminate clean hands.
Gathering equipment:
Running water that can be regulated to warm is most important. Warm water damages the skin less than
hot water, which opens pores, removes protective oils and causes irritation. Cold water is less effective at
removing micro-organisms (Ellis, Knowlis & Bentz, 1992, p. 20) and can be uncomfortable.
The sink should be of a convenient height and large enough that splashing is minimised since damp
uniforms/clothing allow microbes to travel and grow.
Soap or an antimicrobial solution is used to cleanse the hands. The choice is dictated by the condition of
the patient – antimicrobial soap is recommended if the nurse will attend immunosuppressed patients
or the pathogens present are virulent (Potter & Perry, 2001, p. 853). A convenient dispenser (preferably
non-hand-operated) increases handwashing compliance.
Paper towels are preferred for drying hands because they are disposable and prevent the transfer of
micro-organisms.
An orange stick or similar device may be required for cleaning under fingernails.
Turning on the water flow – Using whatever mechanism is available (hand, elbow, knee or foot control),
establish a flow of warm water. Flowing water rinses dirt and micro-organisms from the skin and flushes
them into the sink.
Thoroughly wet hands and apply soap – Do not touch the inside or outside of the sink. The sink is
contaminated and touching will transfer micro-organisms onto the nurse’s hands. Wet hands to above
the wrists, keeping hands lower than elbows to prevent water from flowing onto the arms and, when
contaminated, back onto the cleaner hands. Add liquid soap or an antimicrobial cleanser. Five millilitres
is sufficient to be effective; less does not effectively remove microbes. More soap would be wasteful of
resources. If only bar soap is available, lather and rinse the bar to remove microbes before you start to
wash your hands, and do not put the bar down until you are ready to rinse. Lather hands to above the
wrists.
Cleaning under the fingernails – Under the nails is a highly soiled area and high concentrations of microbes
on hands come from beneath fingernails. Long or artificial nails, or nails with chipped polish, have been
demonstrated to carry a high bacterial load (Boyce & Pittet, 2002). The area under the nails should be
cleansed of debris with either a nail brush or an orange stick, usually during the first handwash of the day.
If the nails become soiled during the shift, this cleaning will need to be done again. Some authors suggest
cleansing the nails prior to washing; others suggest that during washing is more effective. Cleaning this
area under flowing water is most effective for removing debris.
Washing hands – Lather and wash your hands for a period of not less than 15 to 30 seconds before care
or after care if touching ‘clean’ objects (clean materials, limited patient contact such as pulse-taking), and
one to two minutes if engaged in ‘dirty’ activities (Larsen & Lusk, 2006) such as direct contact with excreta
or secretions.
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12
Clinical Skills for Enrolled/Division 2 Nurses
Rub one hand with the other, using vigorous movements since friction is effective in dislodging dirt and
micro-organisms. Pay particular attention to palms, backs of hands, knuckles and webs of fingers. Dirt and
micro-organisms lodge in creases. Lather and scrub up over the wrist, and onto the lower forearm if doing
a longer wash to remove dirt and micro-organisms from this area. The wrists and forearms are considered
less contaminated than the hands, so they are scrubbed after the hands to prevent the movement of microorganisms from a more contaminated to a less contaminated area. Repeat the wetting, lathering with
additional soap and rubbing if hands have been heavily contaminated.
Rinsing hands – Rinse the forearms, hands and fingers, in that order (Altman, 2004), under running water
to wash micro-organisms and dirt from the least contaminated area, over a more contaminated area and
off into the sink. Rinse well to prevent residual soap from irritating the skin.
Drying hands – Using paper towels, pat the fingers, hands and forearms well to dry the skin and prevent
chapping. Damp hands are a source of microbial growth and transfer, as well as contributing to chapping
and then lesions of the hands.
Turning off taps – Using dry paper towels, turn hand-manipulated taps off, taking care not to contaminate
hands on the sink or taps. Carefully discard paper towels so that hands are not contaminated. Turn off
other types of taps with foot, knee or elbow as appropriate. After several washes, hand lotion should be
applied to prevent chapping. Frequent handwashing can be very drying and chapped skin becomes a
reservoir for micro-organisms.
Hand hygiene using a waterless, alcohol-based rub has been demonstrated to reduce the microbial load
on hands when 3mL of the solution is vigorously rubbed over all hand and finger surfaces. The use of
such a rub is effective for minimally contaminated hands. It increases compliance and reduces skin
irritation. Thorough handwashing is still required for contaminated hands or following ‘dirty’ activities
(Pincheansathian, 2004; Morritt et al., 2006) and after several alcohol rubs.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following references and bibliography have
been used to compile the information. The student is expected to have learned the material
surrounding this skill as presented in the references and bibliography that follow. No single
reference is complete on this subject.
References
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Boyce, I. M. & Pittet, D. (2002). Guidelines for hand hygiene in health care settings: Recommendations of the Health Care
Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
Infection Control and Hospital Epidemiology, 23(12), 53–4.
Ellis, J., Knowlis, E. & Bentz, P. (1992). Basic Nursing Skills (5th ed.). New York: Lippincott.
Larson, E. & Lusk, E. (2006). Evaluating handwashing technique. Journal of Advanced Nursing, 10, 546–50.
Morritt, M. L., Harrod, M. E., Crisp, J., Senner, A., Galway, R., Petty, S., Maurice, L., Harvey, A., Hardy, J. & Donnellan, R.
(2006). Handwashing practice and policy variability when caring for central venous catheters in paediatric intensive
care. Australian Critical Care, 19(1), 15–21.
Pincheansathian, W. (2004). A systematic review of the effectiveness of alcohol-based solutions for hand hygiene. International
Journal of Nursing Practice, 10:3–9.
Potter, P. & Perry, A. (2001). Fundamentals of Nursing (5th ed.). St. Louis: Mosby.
Bibliography
Brooker, C. & Nicol, M. (eds). (2003). Nursing Adults: The Practice of Caring. Edinburgh: Mosby.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Larson, E. L., Albrecht, S. & O’Keefe, M. (2005). Hygiene behaviour in a pediatric emergency department and a pediatric
intensive care unit: Comparison of use of 2 dispenser systems. American Journal of Critical Care, 14(4), 304–10.
McCance, K. & Heuther, S. (2002). Pathophysiology: The Biological Basis for Disease in Adults and Children (4th ed.).
St. Louis: Mosby.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Clinical skills competency
COMPETENCY: Pain management (non-pharmacological CRITERIA:
interventions – dry heat and cold)
Y=Satisfactory
S=Requires Supervision
D=Requires Development
DEMONSTRATES: The ability to provide dry heat and
cold therapy
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled Nurse,
2002)
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Verifies there are no contraindications (4.1, 7.1, 7.3,
8.1, 8.2)
3. Demonstrates therapeutic interaction; e.g. gives
patient a clear explanation of procedure (2.1, 3.1, 3.2,
3.4, 7.1, 8.2)
4. Gathers/prepares equipment (7.1, 7.4)
– hot/cold pack
– protective wrapping
5. Washes hands (7.1, 8.1)
6. Displays problem-solving abilities; e.g. provides
privacy, comfort measures, pharmacological pain relief
as ordered (6.1, 7.1, 8.1, 8.3, 8.4)
7. Prepares the hot or cold pack as appropriate
according to manufacturer’s direction (7.1, 8.1)
8. Wraps the pack in a protective cover (7.1, 8.1)
9. Places the covered pack on the treatment site (7.1, 8.1)
10. Times the treatment (7.1, 8.1)
11. Assesses the treatment site after five minutes for
untoward effects (7.1, 8.1)
12. Completes the prescribed treatment and assesses
pain (7.1, 7.2)
13. Cleans, replaces and disposes of equipment
appropriately (8.1, 9.2, 10.2)
14. Documents and reports relevant information (1.1, 1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1)
15. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
13
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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14
Clinical Skills for Enrolled/Division 2 Nurses
Clinical skills competency
Linking theory to practice
COMPETENCY: Pain management: non-pharmacological interventions – dry heat and cold
therapy
Indications for use of heat and cold treatment for pain vary. Pain is the major indicator; however, the
origin of the pain will determine which of these treatments is required or most effective. The patient’s
preference should also be considered, as some patients find cold distressing. The doctor orders the type,
location and duration of heat/cold applications.
Heat is used to increase circulation and thus oxygen and nutrient flow to an area that is painful by
vasodilatation of the arterioles, reduced blood viscosity and increased capillary permeability within
the painful area. The extra circulation/oxygen/nutrients assist in reducing swelling and inflammation,
reducing ischaemia. Heat also reduces muscle spasm and induces muscle relaxation.
Cold is used to promote vasoconstriction and thus decreases oedema and bleeding in an area. Cold reduces
the inflammatory process and decreases contractility of muscles and cellular metabolism. Cold initially
causes hyperaesthesia in the area to which it is applied; later, numbness and paraesthesia set in.
The applications of heat and cold provide cutaneous stimulation, which is an effective pain-relieving
technique.
Assessment of pain is the initial step to determine both the suitability of heat or cold and the location of
the application. Assessment of the patient is done to determine if they are suitable candidates for heat/
cold therapy. Age is an important consideration as the very young and very old tolerate heat poorly. Level
of consciousness, neurosensory impairment and debility need to be established – the patient must be
capable of recognising and appropriately responding to excessive heat or cold. The area to be treated is
determined, then assessed for intact skin (broken skin has increased sensitivity to heat and cold). Altered
circulation in patients with congestive cardiac failure, diabetes mellitus and peripheral vascular diseases
cause reduced circulatory function and heat cannot be dissipated, resulting in local tissue damage; cold is
contraindicated because of vasoconstriction.
Verifying contraindications:
Contraindications for the use of heat therapy are:
• a traumatic injury (within the first 24 hours) because of vasodilatation increasing bleeding and
oedema
• active haemorrhage (or suspected – i.e. internal) because of vasodilatation
• non-inflammatory oedema because heat increases capillary permeability
• acute inflammation (for example, appendicitis) because of increased oedema
• localised malignant tumour because heat accelerates cell metabolism and cell growth and
increases circulation – it may accelerate metastasis
• pregnancy – heat to the abdomen of a pregnant woman can cause mutation in the foetal
germinal cells and affect foetal growth
• skin disorders, since heat can further damage compromised skin
• metallic implants (pacemaker, joint replacements), since metal is an excellent conductor of
heat; some heat applications are contraindicated (for example, diathermy) while others must
be used cautiously (Kozier et al., 2000, p. 957).
Contraindications for the use of cold therapy are:
• open wounds, since cold decreases blood supply to the area and tissue damage or delayed
healing could occur
• impaired circulation, since vasoconstriction further impairs nourishment of the tissues; clients
with Raynaud’s disease will have increased arterial spasms
• cold allergy or hypersensitivity, which could cause hives, erythema, muscle spasm, joint
stiffness or severe hypertension
• shivering, which can cause increased metabolic rate and a raised temperature.
A clear explanation will assist the patient to relax, maximising the effect of the procedure, and gain the
patient’s cooperation, thus reducing the time required to initiate the procedure. It will also increase the trust
the patient has in the nurse. The nurse should outline the preparation (skin inspection, pain assessment,
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Clinical Skills for Enrolled/Division 2 Nurses
15
application of heat/cold) and indication (that is, that heat/cold may or may not completely eliminate the
pain, but it will modify the pain so that the patient can rest, or carry out normal activities of daily living
(ADLs)) and give a brief explanation of the theory behind the use of the treatment (if the patient wants
this information, or is able to understand it).
Gathering the equipment prior to the procedure is a time-management strategy to eliminate trips back
for forgotten equipment. It also serves to assist the neophyte ‘rehearse’ the procedure before going to
the patient’s room, thus increasing confidence. Having all of the equipment on hand increases patient’s
confidence in the nurse, and the nurse’s self-confidence since they will not suffer the embarrassment of
leaving the procedure and returning with a forgotten item.
A hot or cold pack is needed to provide the heat or cold therapy.
Protective wrapping and tape is used to wrap the pack.
Handwashing reduces the number of transient micro-organisms on the nurse’s hands and thus the
incidence of cross-contamination.
The display of problem-solving abilities in relation to this procedure is focused on patient comfort.
Patients who are experiencing pain may or may not manifest the objective symptoms of pain. The nurse
must ascertain the level of pain and decide whether to administer pharmacological pain relief as well
as this treatment to bring comfort to the patient. Other comfort measures need attention as well. These
include but are not limited to proper positioning, adequate support, offering a bedpan or toilet assistance,
attention to associated symptoms such as nausea, provision of privacy and folding bedclothes down to
expose area for treatment. Each situation will be individual and excellent nursing care will encompass a
broad range of comfort measures.
Preparation of the hot/cold pack consists of warming/cooling the pack to an appropriate temperature.
Thermal receptor stimulation declines rapidly in the initial period of treatment. Adaptation of the tissues
to the new temperatures causes the patient to feel that the treatment is ineffective and they may request,
or get for themselves, hotter/colder packs. Some areas of the body are more sensitive to heat (and cold):
for example, the axilla, neck and perineal area. Care must be taken that a pack intended for these areas
is of a more moderate temperature. Hot packs can be warmed in hot water as long as the temperature is
checked prior to application. Commercially prepared hot packs are available. These are re-useable, provide
a consistent heat for a long period of time and are easily ‘triggered’ to produce a safe level of heat by
chemical reaction. Follow the manufacturer’s instructions for their use. Cold packs are usually kept in a
refrigerator or freezer.
The pack is wrapped in a protective cover such as a towel to increase patient comfort and safety. The cover
is taped in place so that pins do not inadvertently puncture the pack. The wrapped pack is placed on the
body part. Pillows may be used to support it in the appropriate position.
Timing of a treatment is an important aspect of both efficacy and safety. If a hot treatment is continued past
the maximal time of effectiveness, the patient is at risk of burns since vasoconstriction occurs as a rebound
with heat, and a less than robust circulation does not dissipate the heat. In cold application, vasodilatation
begins when the skin temperature reaches 15 degrees Celsius, and the treatment is counterproductive and
can cause tissue damage.
The treatment site is monitored at five minutes following application to assess skin condition and comfort.
With cold, pallor and mottled skin is considered a reaction; with heat, pain, burning, excessive redness and
swelling indicate that the treatment should be stopped. The monitoring may be necessary as often as every
five to ten minutes depending on the ability of the patient to report untoward effects or their previous
response to this treatment.
Assess the pain and the skin underlying the application following the treatment.
Cleaning the packs with warm, soapy water and drying them before returning them to storage (cold
packs in the refrigerator or freezer) reduces cross-contamination. Replacing the equipment is a timemanagement strategy as well as a courtesy to colleagues.
Documentation of time, date and type of treatment, location and effectiveness is completed.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following reference and bibliography have
been used to compile the information. The student is expected to have learned the material
surrounding this skill as presented in the reference and bibliography that follow. No single
reference is complete on this subject.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Licensed to: iChapters User
16
Clinical Skills for Enrolled/Division 2 Nurses
Reference
Kozier, B., Erb, G., Berman, A. & Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice (6th ed.). Upper
Saddle River, NJ: Prentice-Hall.
Bibliography
Brown, D. & Edwards, H. (2005). Lewis’s Medical–Surgical Nursing: Assessment and Management of Clinical Problems.
Marrickville, NSW: Mosby Elsevier.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Hochberg, J. (2001). A randomised prospective study to assess the efficacy of two cold therapy treatments following carpal
tunnel release. Journal of Hand Therapy, 14(3) (online). 208–15.
Kozier, B., Erb, G., Blais, K., Johnson, J. & Temple, J. (1993). Techniques in Clinical Nursing (4th ed.). Redwood City, CA:
Addison-Wesley.
Lewis, S., Heitkemper, M. & Dirksen, S. (2004). Medical–Surgical Nursing: Assessment and Management of Clinical Problems
(6th ed.). St. Louis: Mosby.
Monahan, F., Sands, J., Neighbors, M., Marke, J. & Green, C. (2007). Phipps Medical Surgical Nursing – Health and Illness
Perspectives (8th ed.). Philadelphia: Mosby.
Potter, P. & Perry, A. (2001). Fundamentals of Nursing (5th ed.). St. Louis: Mosby.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Clinical skills competency
COMPETENCY: Patient education
DEMONSTRATES: The ability to effectively teach a
skill to a patient
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled
Nurse, 2002)
CRITERIA:
Y=Satisfactory
S=Requires Supervision
D=Requires Development
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Assesses the patient (6.1, 9.2, 10.2)
3. Demonstrates ability to plan care; e.g. prepares
environment, gathers equipment (7.1, 7.4)
4. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure
(2.1, 3.1, 3.2, 3.4, 7.1, 8.2)
5. Individualises standard material (3.1, 3.2, 3.3, 3.4,
3.5, 7.1, 8.2)
6. Provides information at the patient’s level (cognitive)
(3.1, 3.2, 3.3, 3.4, 3.5, 7.1, 8.2)
7. Demonstrates the (psychomotor) skill; has patient
return the demonstration (3.6, 7.1, 9.3)
8. Facilitates affective learning (3.6, 7.1, 9.3)
9. Gives feedback (3.6, 7.1, 9.3)
10. Encourages the patient to use the new skill/
information (3.6, 7.1, 9.3)
11. Documents and reports relevant information (1.1,
1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1)
12. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
17
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Clinical Skills for Enrolled/Division 2 Nurses
Clinical skills competency
Linking theory to practice
COMPETENCY: Patient education
Identifying indications – Patient education is an integral part of the role of a nurse (it is 9.3 of the 2002
ANMC competencies that describe the beginning EN). Early discharge from hospital, increasing complexity
of health care options, financial constraints and increased home health care services have combined to
make the teaching of the skills and knowledge needed to enhance health, independence and quality of life
to patients imperative in quality health care. Patients have a right to receive understandable information
about their health care so they can make informed decisions about treatment options and lifestyle issues.
Offering information relevant to the patient’s health supports their efforts to assume responsibility for
their own health. Patients require knowledge (cognitive domain) about a variety of things that impact
on their health status. These could be medications, pathophysiology and symptoms of complications,
treatments and any number of other sets of information that would help the patient to independence in
their health care. Patients must learn to deal with the affective domain – the feelings, attitudes, interests
and values that motivate them to behave the way they do. Programs to stop smoking, change diet and keep
taking a prescribed medication are based on this internal process that influences the learner’s interaction
with the environment. The psychomotor domain deals with motor and procedural skills. Giving oneself
an injection, deep breathing exercises and changing a dressing are examples of psychomotor skills that
patients learn. Most patient teaching should include the patient’s support person as well, so that there is
reinforcement of the information/attitude/skill once the patient no longer has the direct support of the
health care worker. Including family members in the teaching sessions may assist them to help the patient
in their recovery.
Teaching/learning is a very complex interaction and process. This link is able to give only
a very brief and broad description of the processes involved. Please refer to appropriate
textbooks for a thorough discussion.
Assessing the patient – Patients’ abilities to learn vary. The nurse needs to know the level of knowledge that
a patient has, so that previous knowledge can be built upon. Do not assume a level of previous knowledge.
During an assessment (for example, basic physical assessment) explore the patient’s knowledge of the issues
in question (for example, medications, pathophysiology). Patients’ willingness to learn, ability to learn
and attitude towards learning are influenced by age; gender; level of maturity; level of fear and anxiety;
intelligence; educational, cultural and socioeconomic background; lifestyle; language; and support. The
assessment of these factors allows the teaching to be tailored to the individual and helps to prioritise
learning needs. Patients’ abilities to learn are based on their motivation, their developmental and physical
capabilities, the learning environment, and their ability to take responsibility for their own learning and
the applicability of the information to their situation.
Demonstrating planning ability:
Barriers to learning reduce the effectiveness of any teaching. Identification of the barriers helps the
nurse to implement strategies to eliminate them or reduce their effects. Careful planning of the timing
of the teaching session can reduce physiological barriers such as fatigue and pain. Other physiological
problems such as hearing loss, poor vision, aphasia, organic brain syndrome, loss of muscle strength and
coordination will require the nurse to use other strategies (for example, enlarged visual aids; short sessions;
simple, concrete explanations; multiple repetitions; primary teaching of the significant other).
Psychological barriers to learning such as fear, anxiety and perceived loss of control can be addressed by
first identifying the problem(s) and then discussing important concerns of the patient and reducing these
feelings so that learning can occur. Personalised, accurate, consistent and structured information that is
paced to the individual will reduce the perceived threat of the new learning. Health promotion programs
can be especially challenging because lifestyle behaviour change is difficult. Individuals may be gaining
many positive outcomes and feelings from their current behaviour and feel very negative about making
changes.
Cultural factors may become barriers to learning because there are varying perceptions of illness,
pain and health care in different cultures. The patient’s locus of control, beliefs about religion, gender,
ageing and ethnicity will affect beliefs about health maintenance, and preventing and treating disease.
Communication may be a problem. The nurse must be aware that learning is often culturally based and
take this into account when teaching.
Knowledge of the content is important. The nurse must be perceived by the patient as being competent,
trustworthy and supportive. This results from thorough knowledge of self, the procedural, sensory and
factual aspects of the subject, the ability to be considerate of the learner’s fears and anxieties, and the
flexibility to adapt the delivery of the material accordingly.
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Clinical Skills for Enrolled/Division 2 Nurses
19
Evidence of therapeutic interaction – Good verbal and non-verbal communication skills are imperative.
Leahy and Kizilay (1998, p. 245) outline the following characteristics of a good teacher: accurate, reliable,
dynamic, supportive, attentive and friendly, with genuine positive regard for the learner. Introduce
yourself to the patient, use the preferred name, and explain what you will do and the time frame. Depth
of knowledge to impart is also part of the content and is determined by the patient’s ability and interest,
and the amount of time available for the teaching. Organisation of the information is crucial to the
success of the teaching session. Content should proceed from known to unknown, familiar to unfamiliar,
simple to complex and concrete to abstract. Gagne (1970; cited in Berger & Brinkman Williams, 1998,
p. 529) proposed a four-level hierarchy to sequence information that is particularly adapted to health care
teaching. The four levels are:
1. Establish a factual foundation (present terminology, basic facts).
2. Develop conceptual understanding (show relationships between facts and link facts to form
concepts).
3. Use principles and rules (show relationships between two or more concepts).
4. Engage in problem-solving (infer cause and effect, predict consequences and apply principles
to real situation).
Gathering materials:
Audiovisual materials must take into consideration the patient’s learning ability, vocabulary, reading ability
and concentration span. Audiovisual materials range from written instructions to videotapes or DVDs
presenting material. All audiovisual material must be consistent with the information presented by health
care workers. The nurse should stay with the patient when they initially go over the audiovisual material
to answer questions, direct attention and individualise standardised material.
All equipment for teaching a skill needs to be gathered and checked for completeness and working order
before the teaching begins. Good organisation demonstrates accuracy and reliability. A well-lit room that
is free of distractions makes learning easier.
Any teaching aid used must be assessed for suitability for the learner. Determine the readability of the
written material: for example, print size, complexity of words used, number of concepts/facts presented
and if it is suitable for the patient.
Explain the purpose of each teaching session. Link the new knowledge to previous knowledge. Explain
the purpose of the new skill to increase the patient’s interest and motivation. With the patient, set learning
outcomes for each session since learning is more effective if it is directed towards specified and achievable
outcomes. Individualisation of standardised material promotes consistency and accuracy.
Teaching strategies for the cognitive domain include lectures (informing a group about specific information;
for example, effects of exercise on diabetes mellitus), audio and videotapes, discussion, pictures, posters,
written instructions, slide presentations and one-to-one teaching. Areas for this type of teaching include
sensory, procedural and factual. Sensory information is teaching about the sensations that are likely to
be encountered during a procedure: sights, sounds, smells, movements and physical and psychological
sensations that occur. Procedural information is about what the patient will be expected to do or have done
to them during a procedure, the sequencing, time involved, medications and what the patient can do to
facilitate the procedure. These two types of information are often given only once or twice prior to an event
or during an event and do not require much reinforcement. They are often spontaneous – taking place in
the context of nursing care rather than as a structured teaching session. The provision of such information
about an impending event will assist the patient by decreasing uncertainty and increasing the patient’s sense
of control. Factual information provides knowledge about physiology, pathophysiology and treatment,
and is usually more formally presented. The factual information may need frequent reinforcement if the
patient will use the information on a regular basis. An example is teaching patients about medications.
The major strategy for teaching psychomotor skills is demonstration-coaching.
Demonstrate the skill to be learned from beginning to end, with no interruptions. This allows the patient
to see the skill in its entirety and performed in a seamless and flowing fashion. Demonstrate the skill again,
breaking it into steps that are easily understood and can be explained. Breaking the skill down into small
steps makes the skill easier to learn as it can be assimilated a small amount at a time. Explanations and
rationales for each step increase the ease with which it can be recalled. Repeat the demonstration, with
the patient directing your actions and giving explanations for each of the steps. This process helps the
patient consolidate the progression of the skill without needing to use the motor movements or actually
manipulating the equipment. The patient then handles each piece of equipment and is urged to ask
questions, try parts of the procedure and practise the steps.
A return demonstration is done by the patient with the nurse coaching them through the steps. This gives
the patient a chance to master the fine motor movements of the skill. A second return demonstration
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Clinical Skills for Enrolled/Division 2 Nurses
with the patient coaching themselves through the steps helps them to consolidate and integrate the skill
and the rationale. These steps may require many repetitions before the patient masters the skill. Short
practice sessions are more effective than one sustained practice period. Finally, the patient demonstrates
how to deal with errors and unexpected situational variations (with the nurse coaching as needed). Other
strategies often used in conjunction with demonstration-coaching during psychomotor skill development
are written instructions, posters, pictures and audiovisual presentations.
Affective teaching is usually facilitated by group discussion and role-playing, with the patient as an active
participant. One-to-one discussions offer support during change. Changing values and beliefs is not easy
and requires time and effort, and a well-motivated patient.
Feedback should be given throughout the teaching of the patient. Feedback is information about the quality
and accuracy of a response or action. Feedback needs to be positive to increase self-esteem and therefore the
self-confidence of the patient. Any corrections or negative feedback should only follow positive feedback,
so that budding self-confidence is preserved. Negative feedback is more valuable if it clearly specifies
what the error was, why the response was wrong and the criteria for correcting it. Feedback needs to be
timely – that is, occur at the time of the error to prevent the establishment of inaccurate mind-sets (bad
habits). Feedback must also be honest to preserve the therapeutic relationship. Feedback is essential
in learning psychomotor skills. Frequent feedback is needed during initial sessions with less teacher
feedback as the patient progresses. Patients are encouraged to give themselves feedback and compare
their performance to a standard. The entire teaching session should be evaluated with the patient and the
achievement of learning outcomes emphasised to give the patient a feeling of progression towards a goal.
Encouragement to perform the new skill or display the new knowledge assists the patient to reinforce new
learning and increases the likelihood of the knowledge being incorporated into their repertoire of skills.
Documentation of the teaching provides for continuity of care and provides evidence that time was spent
teaching the patient. What was taught, when it was taught, the method used and whether the learning
outcomes were met or not is documented in the patient’s notes. Note any written material provided.
Referral to other health care personnel and recommendations for further teaching should be noted both
in writing and orally to ensure that there is appropriate follow-up.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following references and bibliography have
been used to compile the information. The student is expected to have learned the material
surrounding this skill as presented in the references and bibliography that follow. No single
reference is complete on this subject.
References
Berger, K. & Brinkman Williams, M. (1998). Fundamentals of Nursing: Collaboration for Optimal Health (2nd ed.). Stamford,
CT: Appleton & Lange.
Leahy, J. & Kizilay, P. (1998). Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia: Saunders.
Bibliography
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Croghan, E. (2005). Assessing motivation and readiness to alter lifestyle behaviour. Nursing Standard, 19(31), 50–2.
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice (7th ed.).
Upper Saddle River, NJ: Prentice Hall.
Mitchell, M. & Courtney, M. (2005). Improving transfer from the intensive care unit: The development, implementation and
evaluation of a brochure based on Knowles’ Adult Learning Theory. International Journal of Nursing Practice, 11,
257–68.
Smeltzer, S. & Bare, B. (2000). Brunner & Suddarth’s Textbook of Medical–Surgical Nursing (9th ed.). Philadelphia: Lippincott
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Clinical skills competency
COMPETENCY: Personal hygiene – bed bath or CRITERIA:
assisted shower
Y=Satisfactory
S=Requires Supervision
D=Requires Development
DEMONSTRATES: The ability to effectively maintain
personal hygiene in a dependent patient
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled
Nurse, 2002)
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Assesses patient for ability to self-care (6.1, 8.1)
3. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure
(2.1, 3.1, 3.2, 3.4, 7.1, 8.2)
4. Gathers equipment (7.1, 7.4)
5. Washes hands (7.1, 8.1)
6. Dons protective apparel as necessary (8.1)
7. Demonstrates problem-solving abilities; e.g.
provides privacy, alters bed height, attends to
environmental temperature, positions patient (2.1,
3.1, 3.2, 3.4, 6.1, 7.1, 8.1, 8.3, 8.4)
8. Carries out the hygiene measure required (bed
bathing, assisted shower) (6.3, 7.1, 8.2)
9. Assesses skin integrity (6.1, 8.1)
10. Cleans, replaces and disposes of equipment
appropriately (8.1, 9.2, 10.2)
11. Documents and reports relevant information (1.1,
1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1)
12. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
21
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Clinical Skills for Enrolled/Division 2 Nurses
Clinical skills competency
Linking theory to practice
COMPETENCY: Maintaining personal hygiene – bed bath or assisted shower
Indications for assisting with personal hygiene are related to the patient’s inability to attend to hygiene
needs on their own due either to their physical/psychological condition or to limitations placed on them
by their treatment. Bathing is a daily hygiene habit that increases in importance when a person is ill or
hospitalised. Bathing removes perspiration, skin oils, dead cells and bacteria, and prevents body odour. It
increases circulation, enhances muscle tone and promotes relaxation and a feeling of wellbeing. Bathing
also presents the nurse with an excellent opportunity to assess the patient’s physical status, such as skin
integrity and ability to self-care. It also enables the nurse to establish and extend a therapeutic relationship.
Showering is generally the preferred method of bathing where possible. An assisted shower occurs when
the patient is showered on a chair or on a shower trolley. A bed bath is given when the patient is physically
unable to get out of bed, or when treatment precludes the possibility of the patient getting up to the shower
(for example, traction). Bed baths range from a complete sponge of the patient by the nurse to an assisted
sponge, where the patient is able to wash when provided with the equipment, and with minimal assistance
from the nurse.
Assessment of the patient prior to assisting with personal hygiene measures is important to prevent
contravening orders, assuming a higher level of activity than is possible or disregarding the patient’s
preferences. Consult the patient’s chart for treatment regimen, activity orders, diagnosis and any orders
specific to the patient’s hygiene. There may be specific assessment formats in the organisational policies.
Assess the patient for activity intolerance, decreased strength and endurance, pain, symptoms related
to their diagnosis, level of sedation, perceptual or cognitive impairment, neuromuscular impairment,
depression or severe anxiety. Discuss their personal hygiene needs and preferences with the patient.
Consistent adherence to lifelong routines can assist to preserve function and slow decline in normal
ageing (Cohen-Mansfield & Jensen, 2005). Such supplies as personal soap, bath gel, emollient creams and
personal sponges mean a great deal to the patient’s feelings of control. Check on the availability and location
of needed supplies or special equipment. Respect for the patient’s personal and cultural preferences must
be shown.
Therapeutic interaction with the patient, such as ascertaining and honouring their preferred items for
a shower, their use of soap or not, and their need for ritual, will increase the extent of the therapeutic
relationship and demonstrate caring. Clear explanations of the procedure will gain patient cooperation.
The bath time is often an excellent time for the nurse to become better acquainted with the patient and
to develop and extend the therapeutic relationship because it is often the longest contact that the nurse
and the patient have during the day. The nurse also has an opportunity to assess the patient physically,
emotionally and psychosocially. The nurse can also assess the patient’s knowledge and conduct health
teaching during the bath time.
Gather equipment as determined during the assessment.
For a bed bath or assisted bath: bath blanket, basin and warm (43–45 degrees Celsius) water, soap or
patient’s preferred cleanser, towels, washcloth (or a bath bag kit), clean clothing and additional items such
as preferred emollient creams, deodorants, clean bed linen and a linen hamper.
For showering: Shower chair or shower trolley if required, soap or shower gel, washcloth, towel, clean
clothing and additional items such as emollient creams and deodorants (may also need plastic sheets and
tape to protect venepuncture sites or incisions).
Wash hands to remove micro-organisms and prevent cross-infection.
Don protective apparel – Use of plastic aprons prevents wetting and soiling of the nurse’s uniform and
thus is a measure for prevention of infection. Clean gloves are used if it is anticipated that there will be
contact with body fluids, including saliva. Most facilities provide unlimited access to clean gloves as a part
of their implementation of standard precautions.
Demonstrating problem-solving abilities – Provide privacy since most aspects of personal hygiene are
considered private by most people in most cultures because of exposure of body areas and the intimate
nature of the routines. Offer the patient a bedpan or urinal before beginning the bed bath to reduce
interruptions and to increase patient comfort. Alter the bed height to reduce strain on the nurse’s back
as reaching over the patient and twisting tends to make back muscles vulnerable to injury. Attend to
environmental temperature and draughts as the patient will have areas of their body exposed and wet
during washing and may easily become chilled. Positioning of the patient to facilitate the care to be given
is an important consideration when attending to hygiene needs. For example, bed baths are most easily
accomplished if the patient is supine and towards the edge of the bed to facilitate reaching over them and
turning the patient.
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Clinical Skills for Enrolled/Division 2 Nurses
23
Carrying out the required hygiene measures – Bed bathing is carried out by one or two nurses, depending
on the condition of the individual patient. Arrange the equipment on the overbed table in order of use
to maximise time use. The patient is assisted into position at the side of the bed. Side-rails are lowered
since the nurse will be in constant attendance. Replace top linen with a bath blanket by placing the fanfolded bath blanket over the sheet. As the patient holds the top of the bath blanket, the sheet and the
bottom of the bath blanket are pulled to the bottom of the bed, preventing exposure of the patient. The
bed linen is removed and folded for re-use, or disposed of in the linen hamper. Remove the patient’s gown
under the bath blanket to prevent exposure. Discard the gown in the linen hamper (if hospital clothing)
or laundry bag.
Use the following techniques to bathe the patient. Use a towel to protect the bed linen while washing
each body part so the patient has a dry bed in which to lie. Use a washcloth folded into a mitt so there
are no loose ends to drag over the patient and annoy or chill them. The washcloth should be damp but
not dripping to prevent discomfort and to ensure thorough washing and rinsing. The water is changed
frequently to ensure warmth and adequate rinsing. The soap is not left in the bath water so that the water
remains clear. Use long, firm strokes as they create friction to remove dirt, oil and bacteria and they are
more relaxing and comfortable than short light strokes. Pay particular attention to areas where skin lies on
skin – axilla, under breasts, abdominal folds, buttock folds and groin. These areas quickly become irritated
if left damp or soapy, and bacteria grow readily in these areas. Expose, wash, rinse and thoroughly dry the
body one part at a time to prevent chilling and embarrassment. Support large joints (elbows, knees) when
the limb is elevated for washing, rinsing and drying. The following order is generally used but may require
adaptation to individual needs:
•
•
•
•
•
•
•
•
•
•
eyes (inner to outer canthus, no soap)
face, neck and ears (check patient preference for soap on the face)
far arm and hand (soak hand in the basin)
near arm and hand (soak hand in the basin)
chest and axillae
abdomen and groin
far thigh, leg and foot (soak foot in the basin)
near leg and foot (soak foot in the basin)
back
genital and anal areas.
Use the guide for perineal care (see the ‘Elimination – patient care’ competency) to complete the genital
area. Replace the bottom sheet with fresh linen. Apply deodorant, moisturisers, emollient cream according
to patient preference. Dress in fresh clothing. If one extremity or side of the patient has decreased range of
motion, or ROM (caused by, for example, IV, surgery or a bandage), dress the affected side first to permit
easier manipulation of clothing over the body part. Replace the bath blanket with the clean top sheet (as
above) and add other linen as required. Discard bath blanket in the linen hamper. Position for comfort
and leave side-rails up and call bell within reach. The patient is encouraged to assist the nurse in any aspect
that they are capable of doing. Patients often prefer to cleanse their own hands and face, and perineal and
anal areas.
Use of a bag bath kit differs little from the traditional bed bath. The bag bath kit contains a number of
disposable washcloths moistened with a non-rinseable emollient cleanser. The entire bag is warmed in the
microwave according to manufacturer’s instructions and brought to the bedside. The nurse uses a fresh
washcloth for each area described above. The skin dries in a few seconds without towelling so the benefits
of the emollient are maximised.
An assisted shower may be done by the patient, if they require minimal assistance, or the patient may
be showered by the nurse, again depending on the condition of the patient. All equipment and linen is
gathered and taken to the shower, so the shower can be completed without interruption, reducing chilling
and tiring of the patient. A non-slip mat is placed on the floor of the shower (so the nurse will not slip
while helping the patient, or if the patient is able to assist themselves so they will not slip). Any incisions
or venepuncture sites are secured with waterproof material to prevent contamination of the site during the
shower. Note that many facilities encourage the showering of intact and healing post-surgical incisions 24
or more hours after surgery. Tap water and showers have been demonstrated to be safe and effective wound
treatments for clean, sutured surgical wounds (Joanna Briggs Institute, 2003). The patient is transferred
to the shower chair or shower trolley and, without exposure, is transported to the shower, or, if mobile,
is escorted to the shower so that the nurse is available if the patient becomes weak. An ‘Occupied’ sign
may be placed on the shower door to ensure privacy. The water temperature is regulated to a comfortable
temperature before the patient is assisted into the shower to prevent injury. The patient is showered in the
shower chair or shower trolley, and is assisted to a stool or directed to use handrails to provide support
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Clinical Skills for Enrolled/Division 2 Nurses
as appropriate. If the patient can be left, the nurse remains close to provide privacy and assistance if
required.
If the nurse is showering the patient, the following techniques are used. Do not shower the face unless
the patient requests it, since many patients feel like they are drowning if water is directed at their face. If
the patient requests a spray of water on their face, direct the spray downward so that water is not forced
up the nostrils or into the eyes. Wash the face with the facecloth formed into a mitt. Wash eyes first, then
face, neck and ears. Ascertain patient preference in regard to soap/bodywash on the face, then proceed to
wash from the neck downward and finish with the perineal area. Rinse thoroughly to prevent irritation
from residual soap. If using a shower trolley, drain the residual water away. Dry the patient rapidly, using
two or three towels, since the entire body surface is wet and exposed leading to chilling by convection.
Take particular care to dry between body folds (for example, between toes, fingers, under breasts, axilla)
to prevent irritation from moisture in between body surfaces. Remember to dry the back/buttocks if the
patient is using a shower chair or shower trolley. Apply deodorants, moisturisers, emollient creams as
preferred by the patient and assist them to dress. Return the patient to their bed or room, and assist them
to a position of comfort.
Clean, replace and dispose of equipment appropriately to leave equipment in useable condition for the
next nurse. This is both a time-management strategy and a courtesy to other staff. Cleaning the shower
area and equipment is done according to hospital policy but usually involves wiping the surfaces, the
non-slip mat and stool, shower chair or shower trolley down with an antiseptic solution to prevent crossinfection, drying up water spills to reduce the risk of falls, and removing all personal or hospital items
such as linen and soap. Some facilities have communal bowls for bed baths; others provide individual or
disposable ones. Institutional protocol for decontaminating bowls should be followed. All soiled hospital
linen is placed in the linen hamper for laundering. Patient’s personal clothing is placed in their laundry
bag for the family to launder.
Document relevant information to include time and date, procedure, response and any areas of skin
breakdown. Some hospitals do not require that personal hygiene be recorded on the nursing notes. Follow
the hospital policy. Any relevant information gleaned during the bath or shower should be passed on
either verbally or in writing so that the health care team remains informed.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following references and bibliography have
been used to compile the information. The student is expected to have learned the material
surrounding this skill as presented in the references and bibliography that follow. No single
reference is complete on this subject.
References
Cohen-Mansfield, J. & Jensen, B. (2005). The preference and importance of bathing, toileting and mouthcare habits in older
persons. Gerontology, 51, 375–85.
Joanna Briggs Institute. (2003). Solutions, techniques and pressure in wound cleansing. Best Practice: Evidence-Based Practice
Information Sheets for Health Professionals, 7(1).
Bibliography
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
McCance, K. & Heuther, S. (2002). Pathophysiology: The Biological Basis for Disease in Adults and Children (4th ed.). St. Louis:
Mosby.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Licensed to: iChapters User
Clinical skills competency
COMPETENCY: Personal hygiene – mouth care, CRITERIA:
shaving, hair care and nail care
Y=Satisfactory
S=Requires Supervision
D=Requires Development
DEMONSTRATES: The ability to effectively maintain
personal hygiene in a dependent patient
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled
Nurse, 2002)
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Assesses patient for ability to self-care (1.3, 1.4, 6.1, 8.1)
3. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure
(2.1, 3.1, 3.2, 3.4, 7.1, 8.2)
4. Gathers equipment as determined by the procedure
(7.1, 7.4)
5. Washes hands (7.1, 8.1)
6. Dons protective apparel (7.1, 8.1)
7. Demonstrates problem-solving abilities; e.g.
provides privacy, alters bed height, attends to
environmental temperature, positions patient (2.1, 3.1, 3.2, 3.4, 6.1, 7.1, 8.1, 8.2)
8. Carries out the hygiene measure (shaving, hair care,
mouth care, nail care) (6.3, 7.1, 8.2)
9. Cleans, replaces and disposes of equipment
appropriately (8.1, 9.2, 10.2)
10. Documents and reports relevant information (1.1,
1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1)
11. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
25
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26
Clinical Skills for Enrolled/Division 2 Nurses
Clinical skills competency
Linking theory to practice
COMPETENCY: Maintaining personal hygiene – mouth care, shaving, hair care and nail care
Identifying indications:
Mouth care is important to assess and maintain the integrity of the oral mucosa and the teeth and gums,
hydrate the mucus membranes, prevent oral infections/lesions, and provide a comfort measure. A clean
mouth can also assist in nutritional intake by stimulating the appetite. The patient can usually accomplish
mouth care with some assistance. Mouth care includes care of dentures.
Hair care (shampooing and maintenance) maintains the integrity of the hair and scalp, improves
circulation and provides a sense of wellbeing.
Shaving the face of a male patient is a variation of hair care. It promotes comfort and contributes to selfconfidence and self-worth.
Nail care removes detritus from under nails and is an important aspect of prevention of autoinfection.
Since long, ragged nails can cause injury, cutting and smoothing them is a safety as well as a comfort
measure.
All of these hygiene measures offer an opportunity to observe and assess the patient and to extend the
therapeutic relationship.
Assessment of the patient prior to assisting them with personal hygiene measures is important to
prevent contravening orders, assuming a higher level of activity than is possible or disregarding the
patient’s preferences. Consult the patient’s chart for treatment regimen, activity orders, diagnosis
and any orders specific to the patient’s hygiene. Assess the patient for activity intolerance, decreased
strength and endurance, pain, symptoms related to their diagnosis, level of sedation, perceptual or
cognitive impairment, neuromuscular impairment, fine and gross motor movement, depression or severe
anxiety. Discuss personal hygiene needs and preferences with the patient. Such supplies as personal
shampoo and conditioner, toothpaste, mouthwash, shaving cream and aftershave mean a great deal
to the patient’s feelings of control. Check on the availability and location of needed supplies or special
equipment.
Therapeutic interaction with the patient such as ascertaining and honouring their preferred items for
shaving, oral care, or their need for ritual, will increase the extent of the therapeutic relationship. Clear
explanations of the procedure will gain patient cooperation.
Gather equipment as determined during the assessment.
For mouth care: towel, toothpaste, toothbrush, small bowl or kidney dish, glass with cool water, mouthwash,
denture cup, denture cleanser and washcloth.
For hair care: preferred shampoo, conditioner, towels; if a bed shampoo is required, add a jug with warm
water, basin, bed trough and a plastic sheet for protecting the bed and extra towels.
For shaving: an electric razor or a basin, towel, razor and shaving soap. Check the patient’s chart regarding
medications or disease, which would influence the choice of either the safety or electric razor (for example,
anticoagulants, thrombocytopenia, depression, confusion, oxygen administration)
For nail care: towel, basin with warm water, clippers or scissors, orange stick and a nail file or emery
board.
Wash hands to remove micro-organisms and prevent cross-infection.
Don protective apparel such as gloves to prevent contact with body fluids and saliva. Use of plastic aprons
prevents wetting and soiling of the nurse’s uniform and thus is a measure for prevention of infection.
Demonstrating problem-solving abilities – Provide privacy since most aspects of personal hygiene are
considered private by most people in most cultures because of the intimate nature of the routines. Alter
the bed height to reduce the strain on the nurse’s back as reaching over the patient and twisting tends
to make back muscles vulnerable to injury. Attend to environmental temperature and draughts as the
patient will have a large area of their body exposed and wet during shampooing and will easily become
chilled. Positioning of the patient to facilitate the care to be given is an important consideration when
attending to hygiene needs. For example, bed shampoos require the patient to remain supine near the
edge of the bed to facilitate rinsing the hair. Mouth care is done with the patient either in a semi-upright
position, upright (conscious patient) or side-lying (unconscious patient) so that fluid does not run down
the trachea. Shaving is done with the patient upright if that is possible.
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Clinical Skills for Enrolled/Division 2 Nurses
27
Carrying out the hygiene measure required:
Mouth care can be done by the patient with assistance or by the nurse. The patient is positioned upright
to simulate the normal situation. A towel is positioned over the chest and shoulders to protect the clothing
from splashes and dribbles. A toothbrush is wet with cool water and a small amount of toothpaste is
applied. The patient is asked to keep the mouth open, and the toothbrush, held at a 45-degree angle, is used
to cleanse every surface of the teeth. Small, circular movements of the toothbrush are applied, starting at
the junction of the teeth and gums and working towards the crown. Light pressure is used to avoid injury.
The inside, outside and flat surfaces of both upper and lower teeth are cleansed. Either the patient sipping
from the water glass or the nurse repeatedly dipping the toothbrush in the water adds fresh water. The
patient spits out the excess toothpaste solution into the bowl as it accumulates. If the patient is unable
to spit out fluid, suction will have to be used. Help the patient to rinse the mouth with mouthwash after
brushing to remove any remaining debris and leave the mouth feeling refreshed. Assessing the patient’s
teeth, gums and mucus membranes is an important consideration when providing mouth care.
Denture care is done when patients are unable to care for their own dental work. Dental plates or bridges
are removed by either the patient or, if unable, by the nurse. If the nurse must remove the dentures or bridge,
a clean washcloth over a gloved hand is used to grasp the plate or bridge because the cloth increases the
friction to facilitate removal and reduces the risk of dropping the expensive item. Still using the washcloth,
the dental plate is held over a plastic cup or padded basin (use a second washcloth and half-fill the basin)
for safety and thoroughly brushed to remove any debris. The plate or bridge is then rinsed and returned
to the patient using a clean, dry washcloth. The patient may prefer to have the plate or bridge soaked in a
cleaning agent overnight. The cleaning agent is placed in the denture cup and dissolved in tepid water. The
plate or bridge is added and remains for several hours to freshen and disinfect the plastic or metal.
Hair washing can be incorporated into a shower. Ask the patient to tip their head backwards and direct
the water stream from the front of the hair backwards to prevent water running over the face. Wet hair
thoroughly and, using the patient’s preferred shampoo, lather well using the balls of your fingers to massage
the scalp and increase circulation. Rinse well, again from the forehead backwards with the head tipped
back. Remove all traces of shampoo to prevent irritation. Wrap the hair in a towel and gently dry it using
short patting movements to prevent damage to the hair shaft. If the patient is unable to get out of bed, a
bed shampoo is done. This entails using a trough designed for bed shampoos, or constructing a trough
out of plastic sheets and towels. The head of the bed may be removed, or the patient may be assisted to the
side of the bed and the trough placed under the head and neck. The tail of the trough runs off the bed and
empties into a basin so that used water is not spilled. A small pillow, protected with a waterproof sheet,
is placed under the patient’s shoulders to increase comfort. A jug with warm (40 degrees Celsius) water
is used to wet the hair. The hair is shampooed using the patient’s preferred shampoo and the balls of the
fingers to massage the scalp to increase circulation. The hair is rinsed, paying particular attention to the
nape of the neck where it is difficult to rinse. Wrap and dry hair as above and remove the bed trough. This
is a skill in itself – do not be discouraged if you must change the patient’s bed linen as well. When the
patient’s hair is towelled dry, style it according to the patient’s preference, taking into consideration the
patient’s ability to care for their hair. For example, long hair is less likely to matt and tangle in a bed-bound
patient if it is braided.
Shaving can be done by the patient with assistance or by the nurse. Determine the patient’s usual routine
(for example, electric or safety razor) and bring equipment to the bedside. Shaving is usually done following
the bath because removing skin oil helps to raise the hair shaft, facilitating its removal. Put the patient in
an upright position, if possible, since this is the usual position the patient would assume. Observe the face
for lesions, raised moles and birthmarks so these can be avoided during shaving and thus prevent injury.
For the safety razor, lather the face with the preferred shaving preparation or soap. Hold the skin taut with
the non-dominant hand and, using short strokes, shave in the direction of the hair growth. This promotes
a closer shave without skin irritation. Rinse the razor between each stroke to keep the cutting edge clean.
Start at the top of hair growth and work down to the neck. Be careful to preserve any moustache or
sideburns established by the patient. Ask the patient to extend his neck to increase tautness of skin and
facilitate hair removal. When hair is removed, rinse the area to remove excess lather and hair and prevent
irritation. Apply the patient’s choice of aftershave which acts as an antiseptic on microabrasions and feels
refreshing. An electric shaver is used in the same manner on dry skin – that is, the skin is held taut and
the razor is moved in the direction of hair growth and from the top downwards. Following the shave, most
men prefer a rinse of the skin and application of an aftershave lotion. Electric shavers are contraindicated
if the patient is receiving oxygen therapy.
Nail care can be done by the patient with assistance or by the nurse. It is usually done following the
bed bath since the nails will have been soaked and softened during the bed bath. Following soaking of
the hands or feet, the skin is carefully dried and the skin and nails assessed. Nail edges may just require
smoothing – feel each one with your index finger. Smooth with the nail file or emery board so there are no
jagged edges to catch on clothing, linen or skin. If the nails are long, and the patient agrees, use the clipper
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28
Clinical Skills for Enrolled/Division 2 Nurses
to remove the excess nail. Cut the nail straight across and smooth with the file or emery board. Take care
that the nail is not cut too short by the lateral folds. Apply emollient lotion to keep the skin soft and supple.
Note that some patients have medical conditions that preclude cutting nails (and most especially toenails),
which is left to experts: for example, peripheral vascular disease and diabetes mellitus, both of which
leave the patient very vulnerable to infection and slow healing if an inadvertent injury occurs. Check the
patient’s chart or with the Registered Nurse to ascertain policy about cutting toenails.
Cleaning, replacing and disposing of equipment appropriately – Shampoo and conditioner bottles are
dried and returned to the patient’s locker for use in the future. These are personal property and should be
treated as such. Razor blades should be disposed of in a sharps container for safety. Electric razors should
be opened and brushed out (over a newspaper or paper towel) with the brush supplied. The brushings
are then folded into the paper and disposed of. Mouth care equipment should be thoroughly rinsed
and returned to the patient’s locker for use in the future. The bowl is cleaned and returned to storage,
either in the patient’s locker or a utility room, depending on the hospital’s practice. Denture cups (if not
disposable) remain at the patient’s bedside, empty when not in use, and somewhere safe when they are in
use. Communal clippers or nail files should be washed and dried before storage to prevent cross-infection.
Emery boards are not cleanable and therefore are individual and kept in the patient’s locker.
Documenting the relevant information – Hygiene measures are usually not specifically documented in
detail unless there are findings or observations to report.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following bibliography has been used to compile
the information. The student is expected to have learned the material surrounding this skill as
presented in the bibliography that follows. No single reference is complete on this subject.
Bibliography
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Kozier, B., Erb, G., Berman, A. & Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice (6th ed.). Upper
Saddle River, NJ: Prentice-Hall.
McCance, K. & Heuther, S. (2002). Pathophysiology: The Biological Basis for Disease in Adults and Children (4th ed.). St. Louis:
Mosby.
Potter, P. & Perry, A. (2001). Fundamentals of Nursing (5th ed.). St. Louis: Mosby.
Springhouse Corporation. (2002). Nursing Procedures Made Incredibly Easy. Philadelphia: Springhouse.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Clinical skills competency
COMPETENCY: Positioning of a dependent patient
DEMONSTRATES: The ability to effectively and safely
move a patient in bed
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled
Nurse, 2002)
CRITERIA:
Y=Satisfactory
S=Requires Supervision
D=Requires Development
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Identifies positions available to use for the patient
(4.1, 8.1)
3. Displays problem-solving abilities, e.g. determines
the need for assistance, secures the bed (1.3, 1.4,
3.1, 3.2, 3.4, 6.1, 8.1, 8.3, 8.4)
4. Gathers equipment (7.4, 9.1)
5. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure
(2.1, 3.1, 3.2, 3.4, 7.1, 8.2)
6. Washes hands (7.1, 8.1)
7. Utilises principles of efficient body mechanics (7.1, 8.1)
8. Moves the patient up in bed (7.1, 8.1)
9. Positions the patient in a side-lying position (7.1, 8.1)
10. Turns the patient towards the nurse (7.1, 8.1)
11. Cleans, replaces and disposes of equipment
appropriately (8.1, 9.2, 10.2)
12. Documents and reports relevant information (1.1, 1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1)
13. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR: ________________________________ .DATE: __________________________________
29
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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30
Clinical Skills for Enrolled/Division 2 Nurses
Clinical skills competency
Linking theory to practice
COMPETENCY: Positioning of a dependent patient
Identifying indications – The skills for moving and turning a patient are important to prevent injury
to the nurse and to the patient. These skills are precursors to positioning the patient in bed. Positioning
in bed promotes comfort, provides proper body alignment and prevents complications of immobility.
Scheduled repositioning of bed-bound or chair-bound patients is effective in reducing the occurrence of
pressure ulcers. The inactive patient may only get exercise during position changes. Position changes for
the immobile or inactive patient should occur second hourly to prevent circulatory damage and disuse
syndrome; assess the skin condition of the patient and provide skin care.
Lifting is hazardous to the nurse’s health. A ‘No lifting’ policy has been implemented in facilities to reduce
the number of nurse and patient injuries. Facilities provide patient-handling equipment (hoists, sliding
sheets, transfer boards, walking belts, adjustable height beds and sometimes baths) to promote patient
and nurse safety. Please follow the facility’s policies and use the provided equipment in regard to this skill.
Occupational health and safety guidelines must be followed.
Identifying positions available for the use of the patient – Various conditions and diseases (fractures,
paralysis, lung disease, congestive cardiac failure) preclude moving patients into some positions.
Tubes, incisions, drains and IV lines may alter the turning/positioning procedure. The patient’s level of
consciousness and ability to comply with instructions may alter positioning. For example, an unconscious
patient would not be positioned in a high upright position because they could not maintain that position.
The preferred positioning for an unconscious patient is the recovery position, but the patient’s specific
medical condition will determine this. A minimum of two staff would be needed to move an unconscious
patient.
Displaying problem-solving abilities – Determine the need for assistance depending on the patient to be
moved, the strength and experience of the nurse, and the conditions of the move. Some patients are able
to assist a great deal; others are totally dependent. Assess each situation to minimise risk and exertion and
maximise effectiveness. Do not hesitate to obtain assistance if there is doubt about your ability to move a
patient with safety to yourself and the patient. Lower the side-rail on the near side so that reaching over the
side-rails will not occur to strain muscles. The opposite side-rail remains in place if that side is unattended
as a safety precaution. Lock the bed wheels to prevent the bed from moving during the procedure. This
is a safety action for both nurse and patient. Anticipate the need for a slidesheet. Raise the bed to an
appropriate and comfortable height for moving the patient. Move tubing, drains and collecting apparatus
to facilitate changes in position. Utilise available lifting equipment as per facility policy.
Gathering equipment:
A slidesheet placed under the patient from the head to below the buttocks can be used to help slide the
patient up in bed. One nurse on each side of the patient rolls the free ends of the slidesheet up close to the
sides of the patient and grasps the rolls close to the patient. The nurses then use good body mechanics to
slide the patient towards the head of the bed.
Pillows are used to: a) provide padding in front of the headboard to protect the head during moves; b)
provide support for various body parts during the move; and c) support the patient in the new position so
that muscles can relax. Other devices – for example, splints, bed cradles and sheepskins – can also assist
with patient comfort.
Lifting devices are available for use with patients who are very heavy or totally incapacitated. Use these
devices as instructed to prevent injury to the patient, to you and to the other nursing staff.
Evidence of therapeutic interaction – Explanations to the patient about what will be done and why will
increase their cooperation. Discussions of the procedure with the patient, including the nurse’s action,
the patient’s expected or desired behaviour and any signals that will be used to synchronise actions, will
increase the effectiveness of the efforts.
Wash hands to prevent cross-contamination.
Utilise principles of good body mechanics to avoid injury to self, to the patient and to other staff. Keep
the body straight and in correct alignment, maintain a stable centre of gravity and have a wide base of
support when positioning a patient. These instructions are commonly outlined in all current nursing and
occupational health and safety references, and are relevant to any form of manual handling. Organisational
policies are very specific about no-lift methods.
Clean and replace used equipment for use another time. This is a time-management strategy and a
courtesy to fellow nursing staff.
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Clinical Skills for Enrolled/Division 2 Nurses
31
Document relevant information to include time and date, procedure, response and any areas of skin
breakdown. Some hospitals do not require that movement and turning be recorded on the nursing notes.
Follow the hospital policy. Any relevant information gleaned during the move should be passed on, either
verbally or in writing, so that the health care team remains informed.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following bibliography has been used to compile
the information. The student is expected to have learned the material surrounding this skill as
presented in the bibliography that follows. No single reference is complete on this subject.
Bibliography
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Australian Safety and Compensation Council. (2005). National Code of Practice for Manual Handling, Canberra: Australian
Government.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Gunningberg, L. (2005) Are patients with or at risk of pressure ulcers allocated appropriate prevention measures? International
Journal of Nursing Practice, 11, 58–67.
Hignett, S. (2002). Systematic review of patient handling activities starting in lying, sitting and standing positions. Journal of
Advanced Nursing, 41(6), 545–52.
Lovely, K. & Gardiner, D. (2005). Aged care facilities: Perceptions of the implementation of no-lift policies. Journal of
Occupational Health Safety, 21(1), 43–9.
McCance, K. & Heuther, S. (2002). Pathophysiology: The Biological Basis for Disease in Adults and Children (4th ed.). St. Louis:
Mosby.
Retsas, A. & Pinikahana, J. (2000). Manual handling activities and injuries among nurses: An Australian hospital study. Journal
of Advanced Nursing, 31(4), 875–83.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Licensed to: iChapters User
Clinical skills competency
COMPETENCY: Range of motion exercises
DEMONSTRATES: The ability to effectively and safely
maintain a patient’s joint mobility or teach the patient
to do so
PERFORMANCE CRITERIA (numbers indicate ANMC
National Competency Standards for the Enrolled
Nurse, 2002)
CRITERIA:
Y=Satisfactory
S=Requires Supervision
D=Requires Development
Y
S
D
1. Identifies indication (4.1, 7.1, 8.1)
2. Assesses all joints (6.1, 8.1)
3. Evidence of therapeutic interaction with the patient;
e.g. gives patient a clear explanation of procedure
(2.1, 3.1, 3.2, 3.4, 7.1, 8.2)
4. Gathers equipment (7.1, 7.4)
– bed in correct position
– small and large pillows as necessary
5. Considerations for implementation are understood
(4.1, 7.1, 8.1, 9.2, 10.2)
6. Washes hands (7.1, 8.1)
7. Assists the patient to move each joint through its
entire range of motion (3.6, 7.1, 8.1, 9.1, 9.3)
8. Teaches the patient to accomplish range of motion
exercises with minimal assistance (3.6, 7.1, 8.1, 9.1, 9.3)
9. Documents and reports relevant information (1.1, 1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1)
10. Demonstrates ability to link theory to practice (5.1, 5.2)
STUDENT: ____________________________________________
CLINICAL SUPERVISOR:_________________________________ .DATE: __________________________________
32
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Clinical Skills for Enrolled/Division 2 Nurses
33
Clinical skills competency
Linking theory to practice
COMPETENCY: Range of motion exercises
Identifying indications – Inactive patients do not move their joints through the entire range of motion
because of limits to their activity. Over time, reduction in the range of movement of the joints occurs due
to shortening of ligaments and tendons. The result is a non-functional joint and eventually a contracture of
that joint. Impaired physical mobility may be due to unconsciousness, a stroke or paralysis, post-operative
discomfort (or limitations due to such things as mastectomy), brain damage or pain. Knowledge of the
diagnosis helps to determine the exercises needed and those that are contraindicated. Regular exercise
of the joints prevents spasticity, muscle wasting and shortening of tendons and ligaments (contracture
development).
Assessing the joints – Check care plan for any specific instructions. Assess the patient’s ability to move
each joint. There is no need to do range of motion exercises on a joint that is moving adequately and which
is moved as part of activities of daily living. If a joint is weak or immobile, it must be moved.
Evidence of therapeutic interaction with the patient – The patient’s cooperation will be gained by giving
the patient a clear explanation of the exercises and reasons for them.
Gathering and adjusting equipment prior to initiation of the procedure increases efficiency. Positioning
the bed at the nurse’s waist level keeps the activity near the nurse’s centre of gravity, thereby minimising
stress on the nurse’s muscles. This reduces energy expenditure and also reduces friction and shearing
forces on the patient’s skin. Small and large pillows need to be handy for use to support the patient in sidelying positions. The pillows remain with the patient throughout their hospitalisation.
Understanding considerations for implementation – Range of motion should be carried out within the
pain-free range. Watch the patient for non-verbal expressions of pain during the exercise: facial grimaces,
withdrawal of the limb or tensing of the body indicate pain. If a joint movement is painful the therapist
should be consulted. Therapists have the training and experience to stretch tight joints and to release
contractures. The increased exercise level involved in range of motion exercises will cause fatigue for many
patients. Do not continue the exercises to the point of exhaustion.
Types of range of motion exercises are detailed below.
Passive range of motion exercises are those in which the nurse moves each of the patient’s joints through
its full range of movement with little or no input from the patient. These exercises maintain joint mobility
only. This assumes a level of knowledge on the nurse’s part of each joint’s range of movement.
Active range of motion exercises are those in which the patient moves their own joints through the full
range of movement. The patient must be motivated to be actively involved. Patients can be taught to do
active range of motion exercises on weak or inactive joints. They may use adjacent muscles to move a
joint. These exercises maintain/increase muscle strength, endurance and cardio-respiratory function in
an immobile person.
Active assisted range of motion exercises occur where the patient uses one part of the body to move
another joint in their body through its range of motion. An example of this would be the patient who has
had a cerebrovascular accident and uses the stronger arm and leg to move the weaker ones through their
range of motion.
Wash hands to reduce cross-contamination.
Performing range of motion exercises – If the patient is able, a sitting position for the upper body range
of motion exercises is most effective. The patient should be well supported in this position with their feet
flat on the floor. If the patient is unable to sit, they are positioned in the supine position with heels close
together and arms resting at the sides. The therapist may position the patient in the prone position for
some extension and flexion exercises. If the patient is unable to assume a prone position, left and right
side-lying positions are used. The patient must be fully supported in the side-lying positions so that during
movement of the joints they are not pulled out of the position.
Encouraging the patient to do activities of daily living increases the range of motion of all joints and
reduces the need to do range of motion exercises. During the exercises, a specific systematic pattern should
be adopted so that no joint is forgotten. Start the exercises gradually and work slowly. Movement should be
smooth and rhythmic to increase comfort for the patient.
During passive range of motion exercises, support each joint to prevent over-extension. Move the joint
slowly and smoothly and as per care plan. Do these exercises on a scheduled basis. Passive range of motion
exercises can be incorporated into daily hygiene routines. Move each joint to the point of resistance but
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34
Clinical Skills for Enrolled/Division 2 Nurses
not pain. Use gentle pressure, not force. Start and finish with each joint in its normal neutral position. Take
care to note the patient’s facial expressions and other non-verbal expressions for evidence of pain.
The following table outlines the movements possible in each joint in the positions indicated. For detailed
discussion with pictures of range of motion exercises, see Altman (2004, pp. 534–8) and Crisp and Taylor
(2005, pp. 1386–91).
Joint
Supine
Prone
neck (active)
flex, extend, lateral flex, rotate
hyperextend
shoulder
flex, extend, adduct, abduct, internal and hyperextend
external rotation
scapular
protract
elbow
flex, extend
wrist
flex, extend, ulnar and radial deviation,
pronate and supinate
fingers
flex, extend, adduct and abduct
thumbs
flex, extend, oppose
hips
flex, extend, adduct and abduct
hyperextend
knees
flex, extend
flex, extend
ankles
dorsiflex, plantar flex, invert, evert
dorsiflex, plantar flex
Toes
flex, extend, adduct and abduct
retract
Teaching the patient to do range of motion exercises The patient needs to know what (the joint that is
being exercised), why (to maintain mobility and allow specific activities, especially pleasurable ones, to be
done) and how (use a show-and-tell technique). Try to make each session relaxing since the patient will
benefit by taking a more active part.
Documentation on range of motion exercises includes an initial notation of the joints to be exercised and
then daily notes that the exercises have been completed along with any changes noted.
NOTE
These notes are summaries of the most important points in this assessment/procedure. These
notes are not exhaustive on the subject. The following references and bibliography have
been used to compile the information. The student is expected to have learned the material
surrounding this skill as presented in the references and bibliography that follow. No single
reference is complete on this subject.
References
Altman, G. B. (2004). Delmar’s Fundamental and Advanced Nursing Skills (2nd ed.). Clifton Park, NY: Delmar.
Crisp, J. & Taylor, C. (eds). (2005). Potter & Perry’s Fundamentals of Nursing (2nd ed.). Sydney: Mosby.
Bibliography
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice (7th ed.). Upper
Saddle River, NJ: Prentice Hall.
McCance, K. & Heuther, S. (2002). Pathophysiology: The Biological Basis for Disease in Adults and Children (4th ed.). St. Louis:
Mosby.
Smeltzer, S. & Bare, B. (2000). Brunner & Suddarth’s Textbook of Medical–Surgical Nursing (9th ed.). Philadelphia: Lippincott.
Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.