Checkist For NCM 100 (Skills)

COLLEGE OF NURSING
PERFORMANCE EVALUATION TOOL

FUNDAMENTALS OF NURSING PRACTICE
HYGIENE
SHAMPOOING and COMBING THE HAIR
PROCEDURE
5 4 3 2 1 REMARK
Identify yourself. Explain the procedure to the client or
relative
Assist patient to the sink. If patient cannot walk alone,
provide a weight gait device or wheelchair. (apply
techniques in transferring client from bed to
wheelchair or chair or stretcher)
Perform hand hygiene and other infection control
Wear gloves if needed
Position wheelchair at the sink with the back facing you
Put a towel on the patients shoulder and a rolled towel
under the patients neck/nape
Put a piece of cotton ball inside the two ears and a
dampen wash cloth over their eyes to prevent water
from entering the eyes and ears (remove eye glasses)
Adjust the water temperature.
With the use of a shower tool, wet hair thoroughly
Apply shampoo and work on a lather.
> Massage scalp using finger pads not the finger nails
in circular motion to promote blood circulation and
relaxation. Rinse well, shampooing may be repeated
twice
Squeeze the end of the hair strands to remove excess
water and dry well.
Assist patient to raise his/her head off the sink. Put a
dry towel around head.
Continue drying the hair. Use hair dryer
Comb and style hair according to patients preferences.
Avoid juvenile hairstyle if client is an older client
Place a towel across the shoulders. Place a
towel across the pillow if the patient is in bed
Part the hair and divide it into two (2) main
sections. Divide one side into two (2) sections.
Brush/ comb the hair. Start at the scalp and
brush toward the hair ends
Remove the towel
Let the patient put on the eye glasses.
Assist client to assume a comfortable position
Offer a mirror to the client for viewing himself/herself

Place the signal light within reach
Put all soiled materials in a hamper. Rearrange
materials to its proper places.
Remove gloves and do hand washing
Document procedures in the patients chart.
Students Signature:_______________
Date:_____
Instructor Signature________________
Date:__________
Comments/Suggestions:__________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
COLLEGE OF NURSING
HYGIENE
Eye care
PROCEDURE
Position on a sitting positon or lying position.
Dip one cotton ball into a clean water, squeeze and
wipe each eye starting from the inner canthus going to
outer canthus. Throw the used cotton ball into a plastic
container
Repeat procedure on the other eye
Use separate cotton balls on each eye
Document the procedure and other pertinent data on
the patients chart such as: redness, eye discharge
Date:_____
5 4 3 2 1 REMARK
Date:__________
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COLLEGE OF NURSING
HYGIENE
Shaving
PROCEDURE
Identify the patient. Introduce self. Explain the
procedure.
Gather the needed materials:
Wash basin
Wash cloth
Face towel
Bath towel
bath thermometer
mirror
shaving cream or soap
shaving brush
razor or shaver
After shave lotion/cologne
Tissues
Paper towel
Disposable gloves
Place the paper towels on the overbed table. Arrange
items on top of it.
Provide for privacy.
Raise the head of the bed to a level for good body
mechanics.
Fill the wash basin. Water temperature should be
approximately 115 degrees F (46 degrees C)
Place the basin on the overbed table on top of the
paper towels.
Lower the side rail.
Position the patient in semi Fowlers position if allowed
or tolerated or on his back
Adjust lighting so that you can clearly see the patients
face.
Place the bath towel over the chest.
Position the overbed table within easy reach and at a
comfortable working height.
Put on the gloves.
Wash the patients face. Do not dry.
5 4 3 2 1 REMARK
PROCEDURE
Place a washcloth or face towel in the water and wet it
thoroughly. Wring it out.
Apply the wash cloth or towel to the patients face to
soften the beard. Remove it after 3 to 5 minutes.
Apply shaving cream to the face with your hands. If
apply lather, use a shaving brush.
Tighten the razor blade to the razor.
Hold the skin taut with your non-dominant hand
Shave in the direction of hair growth. Use shorter
strokes around the chin and lips
Rinse the razor often and wipe with tissues.
Apply direct pressure to any bleeding areas.
Wash off any remaining shaving cream or soap. Dry
with a towel.
Apply after shave lotion if requested
Move the overbed table to the side of the bed.
Remove the gloves.
Make sure the patient is comfortable and safe.
Place the signal light within reach
Raise the side rail
Lower the bed to its lowest position.
Clean and return equipment and supplies to their
proper place. Discard disposable items
Wipe off the overbed table with the paper towels.
Discard the paper towels.
Unscreen the patient
Place soiled linen in the linen hamper.
Wash your hands.
Document the procedure on the patients chart and
report any nicks or bleeding to the physician.
Date:_____
5 4 3 2 1 REMARK
Date:__________
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COLLEGE OF NURSING
HYGIENE
Oral Hygiene/Mouth Hygiene:
a. ASSISTING THE PATIENT TO BRUSH THE TEETH
PROCEDURE
Identify the client. Introduce self. Explain the procedure
to the patient and relative.
Gather the needed materials.
Toothbrush
> face towel
Toothpaste or dentrifice
> paper towels
Mouthwash
> clean gloves
Dental floss
> Water glass with
cool Straw
water
Emesis basin
items on top of it.
Wash hands
Raise the head of the bed to a level where the patient
can brush with ease.
Place the towel over the patients chest to protect the
gown and linen from spills.
Lower the side rail for your working area
Move the overbed table in front of the patient. Adjust
the table height so that the patient can work on ease
Allow the patient to brush the teeth.
Move the overbed table next to the bed when the
patient is finished. Lower it to a level appropriate for
the patient
Make sure the patient is comfortable
Place the signal light within the patient reach
Raise the side rail
Clean and return equipment to its proper place.
Wipe off the overbed with the paper towels and discard
it properly.
Unscreen the patient.
Place soiled linen in the linen hamper
5 4 3 2 1 REMARK
PROCEDURE
Wash hands.
Document or report observations to the doctor.
Date:_____
5 4 3 2 1 REMARK
Date:__________
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COLLEGE OF NURSING
HYGIENE
Oral Hygiene/Mouth Hygiene:
b. BRUSHING THE PATIENTS TEETH
PROCEDURE
to the patient and relative.
Wash hands.
Gather the needed materials.
items on top of it.
Provide for privacy
Raise the head of the bed to a level for good body
mechanics
Raise the head of the bed so that the patient can sit
comfortably
Position the patient on the side near you if he or she
cannot sit up
Lower the side rail
gown and linen from spills.
Position the overbed table so that you can reach it with
ease. Adjust the height as needed.
Put on the gloves.
Apply toothpaste to the tooth brush.
Hold the tooth brush over the emesis basin. Pour some
water over the brush
Brush the patients teeth gently.
Let the patient have some water to rinse the mouth.
Hold the emesis basin under the patients chin. Have
the patient repeat rinsing as necessary.
Floss the patients teeth
Let the patient use mouthwash. Hold the emesis basin
under the chin.
Remove and discard the gloves.
Make sure the patient is comfortable.
5 4 3 2 1 REMARK
PROCEDURE
Place the signal light within reach of the patient
Raise the side rail.
Lower the bed to its lower position
Clean and return the materials to its proper place
Wipe off the overbed table with the paper towels and
discard them.
Place soiled linen in the linen hamper
Wash hands
Document/report your observations to the physician
Date:_____
5 4 3 2 1 REMARK
Date:__________
______________________________________________________________________
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COLLEGE OF NURSING

HYGIENE
c. FLOSSING THE PATIENTS TEETH
PROCEDURE
Identify the patient. Introduce yourself. Explain the
procedure
Wash hands
Gather the necessary materials
items on top of it.
Place the bed an appropriate level for good body
mechanics
Raise the head of the bed so that the patient can sit
comfortably. Position the client on the side near you if
he or she cannot sit up.
gown and linens from spills
Position the overbed table so that you can reach it with
ease. Adjust the height as needed.
Wash your hands
Put on the gloves
Break off an 18 inches pc. of floss from the dispenser
Hold the floss between the middle finger of each hand
Stretch the floss with your thumbs
Start at the upper back tooth on the right side and work
around to the left side
Move the floss gently up and down between the teeth
Move to a new section of floss every second tooth
Floss the lower teeth. Hold the floss with your index
fingers. Use back and forth motions and go under the
gums as you did for the upper teeth. Start on the right
side and work around to the left side
Let the patient rinse his /her mouth. Hold the emesis
basin under the chin. Repeat rinsing as necessary.
5 4 3 2 1 REMARK
PROCEDURE
5 4 3 2 1 REMARK
Follow steps 19 t0 20 for brushing the patients teeth

d. DENTURE CARE
Identify client. Introduce self. Explain the procedure
Collect needed materials:
Emesis basin
Towel
Denture cup
Gloves
Gauze square
Toothbrush
Tooth paste
Wash your hands.
Place the towel over the patients chest
Ask the patient to remove the dentures. Carefully place
them in the emesis basin
If the patient cannot do so, put on gloves and remove
the dentures using gauze squares
Take the emesis basin, denture cup, brush, and
denture cleaner or toothpaste to the sink
Rinse each denture under warm running water. Return
them to the denture cup.
Line sink with a towel and fill it with water.
Apply denture cleaner or toothpaste to the brush.
Brush the dentures.
Rinse the dentures under warm running water. Handle
them carefully, do not drop them.
Place the denture in the denture cup. Fill it with cool
water until the dentures are covered.
Clean the emesis basin.
Bring the denture cup and emesis basin to the bedside
table
Lower the side rails.
Position the patient for oral hygiene.
Assist the patient to rinse out his or her mouth with
mouth wash. Hold the emesis basin under the chin
Ask the patient to insert the dentures. You must insert
them if the patient cannot.
Remove the gloves.
PROCEDURE
Put the denture cup in the top drawer of the bedside
stand if the dentures are not reinsesrted
Make sure the signal light is within reach
Raise the side rails.
Clean and return equipments to its proper place.
Discard disposable materials
Wash your hands
Document procedure in the patients chart and other
pertinent data. Report observations to the doctor.
Date:_____
Date:__________
______________________________________________________________________
______________________________________________________________________
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COLLEGE OF NURSING
HYGIENE
GIVING FEMALE PERINEAL CARE
PROCEDURE
procedure.
Gather the needed materials
Soap dish with soap
Three to ten disposable washclots or a small
package of cotton balls
Bath towel
Bath blanket
Bath thermometer
Waterproof pad
Disposable gloves
Paper towels
Disposable bags
items on top of it.
Raise the bed to a level appropriate for good body
mechanics
Cover the patient with a bath blanket. Move top linens
to the foot of the bed.
Position the waterproof pad under her buttocks
Drape the patient
Fill the wash basin. Water temperature should be
approximately 105 degrees F to 109 degrees F ( 41-43
degrees C)
paper towels.
Help the patient flex her knees and spread her legs.
Put on the gloves
Put the washcloth in the basin. Squeeze out excess
water before using them.
Apply soap to a washcloth
5 4 3 2 1 REMARK
PROCEDURE
5 4 3 2 1 REMARK
Separate the labia. Clean downward from front to back
with one stroke. Discard the washcloth into the
disposable bag.
Use a mitted washcloth
Repeat 17 and 18 until the area is clean.
Rinse the perineum with a washcloth. Separate the
labia. Stroke downward from front to back.
Pat the area dry with towel.
Fold the blanket back between the clients legs
Help the patient lower her legs
Remove the waterproof pad under the clients buttocks.
Remove gloves and discard them into the bag.
Return linens to their proper position remove the bath
blanket.
Raise the side rail. Place the signal light within reach.
Clean and arrange reusable materials
Discard all non reusable materials.
Wipe off the overbed table with the paper towels and
discard them
Remove gloves and do hand washing
Document the procedure in the patients chart and
other pertinent data such as:
a. a. Any odors
b. Redness, swelling, discharge or irritation
c. Patient complaints of pain, burning or other
discomforts
Date:_____
Date:__________
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COLLEGE OF NURSING
HYGIENE
GIVING NAIL AND FOOT CARE
PROCEDURE
5 4 3 2 1 REMARK
procedure.
Gather the needed materials
Wash basin
Bath thermometer
Bath towel
Face towel
Wash cloth
Emesis basin
Nail clippers
Orange stick
Emery board or nail file
Lotion or petroleum gel
Paper towels
Disposable bath mat
items on top of it.
Help the patient to a bedside chair. Place the signal
light within reach.
Place the bath mat under the patients feet.
Fill the wash basin. Water temperature should be 109
degrees F to 111 degrees F (43 to 44 degrees C)
Put on gloves.
Place the basin on the bath mat. Help the patient put
the feet into the basin.
Position the overbed table in front of the patient. It
should be low and close to the patient.
Fill the emesis basin. Water temperature should be 109
degree F to 111 degrees F ( 43 to 44 degrees C).
paper towels.
Place the patients fingers into the basin. Position the
arms so that he or she is comfortable
Let the feet and fingernails soak for 20 to 30 minutes.

Re warm the water in 10 to 15 minutes
Clean under the fingernails with the orange stick.
PROCEDURE
Remove the emesis basin and dry the fingers
thoroughly
Clip fingernails straight across with the nail clippers.
Shape nails with an emery board or nail file.
Push cuticles back with the orange stick or a washcloth
Move the overbed table to the side.
Scrub callused areas of the feet with a washcloth
Remove the feet from the basin. Dry thoroughly.
Apply lotion or petroleum gel to the feet.
Assist the patient back to bed and to a comfortable
position. Place signal light within reach.
Clean and return equipment and supplies to their
proper place. Discard disposable supplies
Take soiled linen to the dirty utility room
Remove gloves and do hand washing.
other pertinent data such as:
a. reddened, irritated or callused areas
b. Breaks in the skin
Date:_____
5 4 3 2 1 REMARK
Date:__________
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COLLEGE OF NURSING
HYGIENE
GIVING A BACK MASSAGE
PROCEDURE
procedure.
Gather the needed materials:
Bath blanket
lotion
Bath towel
Wash hands
Raise the bed to an appropriate level for good body
mechanics.
Position the patient in the prone or side lying position.
With the clients back toward you.
Expose the back, shoulders, upper arms, and the
buttocks. Cover the rest of the body with bath blanket.
Lay the towel on the bed along the back
Warm the lotion bottle lotion under running water or rub
some lotion between your hands
Explain that the lotion may feel cool and wet.
Apply lotion to the lower back area.
Stroke up from the buttocks to the shoulders.
Stroke down over the upper arms.
Stroke up the upper arms, across the shoulders, and
down the backs to the buttocks.
Use firm strokes. Keep your hands in contact with the
patient skin.
Repeat step 13 for at least three minutes
Knead by grasping tissue between your thumb and
fingers. Knead half of the backs starting at the buttocks
and moving up to the shoulders.
Then knead down from shoulders to the buttocks.
Repeat on the other half of the back
Massage bony areas. Use circular motion with the tips
of your fingers and tips of middle fingers.
5 4 3 2 1 REMARK
PROCEDURE
Use fast movement to stimulate and slow movement to
relax the patient.
Stroke with long, firm movements to end the massage,
tell the patient you are finishing.
Cover the patient. Remove the towel and bath blanket.
Make sure the patient is comfortable.
Raise the side rail. Place the signal light within reach.
Return the lotion to its proper place.
Wash your hands.
other pertinent data
Date:_____
5 4 3 2 1 REMARK
Date:__________
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COLLEGE OF NURSING
HYGIENE
Changing Hospital Gowns
PROCEDURE
5 4 3 2 1 REMARK
Identify patient. Introduce yourself. Explain the
procedure.
Wash your hands
Provide for privacy
Untie the back of the gown. Free parts of the gown that
the patient is lying on.
Remove the gown from the arm with no IV.
Gather up the sleeve of the arm with the IV. Slide it
over the IV site and tubing.
Remove the arm and hand from the sleeve
Keep the sleeve gathered. Slide your arm along the
tubing to the bottle.
Remove the bottle from the pole. Slide the bottle and
tubing through the sleeve. Do not pull on the tubing.
Keep the bottle above the patients arm.
Hang the iv bottle on the pole.
Gather the sleeve of the clean gown that will go on the
arm with the IV infusion.
Remove the bottle from the pole. Quickly slip the
gathered sleeve over the bottle at the shoulder part of
the gown.
Slide the gathered sleeve over the tubing, hand, arm
and IV site. Then slide the sleeve onto the patients
shoulder.
Put the other side of the gown on the patient
Fasten the back of the gown.
Place the signal light within reach.
Raise the side rail. Lower the bed to its lowest position.
Take soiled linen to the dirty utility room
Wash your hands
Date:_____
Date:__________
______________________________________________________________________
COLLEGE OF NURSING

HYGIENE
Complete Bed bath
PROCEDURE
to the patient and relative
Gather necessary materials:
Basin
> clean gown
Soap (optional)
> Deodorant
Wash cloth
> Comb or brush
2 towels
> Disposable gloves
Bath blanket
Lotion
Materials for shampooing
Materials for eye care
Materials for oral care
Materials for perineal care
Materials for foot and nail care
Materials for changing the bed linen
Clean hospital gown
Place supplies over the bedside table.
Fill basin with warm water
Perform hand hygiene and other infection control
Wear gloves (clean gloves) if you are about to handle
secretions, excretions, urine, feces, soiled linens or
other body fluids.
Provide privacy.
Lower the side rails where you will work.
Offer bed pan or urinals if patient wishes to urinate
first. Side rails up. Discard the urine. Handwash and
wear a new, clean gloves.
Ask the patient to remove eye glasses if with these.
Put eye glasses in the glass case. Put the case inside
the bedside stand.
Place towel over the patients chest.
Perform shampooing and combing the hair procedure
(follow shampooing and combing the hair procedure)
5 4 3 2 1 REMARK
Perform eye care (follow eye care procedure)

Perform oral care (follow oral care procedure)
PROCEDURE
5 4 3 2 1 REMARK
Perform shaving the beard and mustache (follow
procedure for these)
While maintaining the cover of the arm farthest from
you with a bath blanket, uncover the arm near you,
place a towel lengthwise under this arm, wash, rinse
and dry it paying attention on the axilla or armpit.
Use a circular motion with a mitten on your
dominant hand.
Make a mitten of washcloth in hand
While maintaining the cover of the leg farthest from you
with a bath blanket, uncover the leg near you, place a
towel lengthwise under this leg, wash, rinse and dry it
paying attention on behind leg.
Use a circular motion with a mitten on your
dominant hand.
Make a mitten of washcloth in hand
Put patient on his side away from you. Let patient hold
on the raised side rail or put a pillow in between legs.
Put towel in a lengthwise manner
Wash, rinse and dry back and buttocks in a circular
motion with a mitten on your dominant hand.
Apply and rub lotion on the patients back and
buttocks.
Repeat the procedure on the other side of arm and leg
Refill water as needed
Always side rail up before leaving the patient on
bed
Perform perineal care. Follow procedure.
Change the clients gown (Follow procedure)
Perform bed making( occupied or unoccupied). Follow
procedure.
Place patient in a comfortable position. Place signal
light within patients reach. Side rails up.
Remove all soiled materials and discard them properly
according to agency policy
Clean and return other materials to its proper places.
Remove and discard gloves properly and wash hands.
Inform relatives/visitors that they may return to the
room
Document procedures and other pertinent data on the
clients chart.
Date:_____
Date:__________
COLLEGE OF NURSING

CHANGING LINENS IN AN UNOCCUPIED BED
PROCEDURE
Identify the patient, introduce self and explain the
1 procedure
Gather the necessary materials:
2
Bottom sheet
Draw sheet
Mattress pad
Top sheet
Pillowcase
Antiseptic solution,
Washcloth, and towel
Nonsterile gloves (2 pairs)
Linen bag hamper
3 Assess condition of blanket and or/bedspread
4 Gather linens and gloves.
Place linens on a clean, dry surface in reverse order
5 of usage at the clients bedside ( pillowcases, top
sheet, draw sheet , bottom sheet
6 Apply gloves
Inquire about the clients toileting needs and attend as
7 necessary
8 Assist client to a safe, comfortable chair
Position bed: flat, side rails down, adjust height to a
9 waist level
Remove and fold blanket and or bed/spread.
10
If clean and reusable, place on clean work area
Remove soiled pillowcases by grasping the closed end
11 with one hand and slipping the pillow out with the other
Place the soiled cases on top of the soiled
sheet, and place the pillows on clean work area
Remove soiled linens:
12
Start on the side of the bed closest to you
Free the bottom sheet and mattress pad by
5 4 3 2 1 REMARK
lifting the mattress and rolling soiled linens to

the middle of the bed
Go to the other side of the bed, repeat action
13
14
15
16
17
PROCEDURE
Fold soiled linens:
Head of bed to middle, foot of bed to middle
Place in linen bag or hamper, keeping soiled
linens away from uniform
Check mattress.
> If the mattress is soiled, clean it with antiseptic
solution and dry it thoroughly
Remove gloves, wash hands, and apply a second pair
of clean gloves
Open the clean mattress pad lengthwise onto the bed
with the seamed side of the sheet toward the mattress.
> Unfold half of the pads width to the center crease
and smooth the pad flat.
> If there are elastic bands to hold the pad in place,
slide them under the corners of the mattress
Proceed with placing the bottom sheet onto the
mattress.
Date:_____
5 4 3 2 1 REMARK
Date:__________
COLLEGE OF NURSING
CHANGING LINENS IN AN OCCUPIED BED
PROCEDURE
Identify the patient, introduce self and explain the
1 procedure
Gather the necessary materials:
2
Linen hamper
Pillowcase
Bath blanket
Top sheet, draw sheet, bottom sheet
Blanket
Nonsterile gloves (2 pairs)
3 Bring equipment to the bedside
4 Apply gloves
Remove top sheet and blanket.
5
Loosen bottom sheet at foot and sides of bed
Lower side rail nearest to you if necessary for
access
Client may be covered with a bath blanket
6 Position client on side, facing away from you
Reposition pillow under head
Fanfold or roll bottom linens close to client toward the
7 center of the bed
8 Smooth wrinkles out of mattress.
Place clean bottom linens with the center fold
nearest the client
Fan-fold or roll clean bottom linens nearest
client and tuck under soiled linen.
Maintain an adequate amount of sheet at head
and foot of bed for tucking
Mitter bottom sheet at head of bed, then at foot of bed.
9
To miter, lift the mattress and tuck the sheet
over that e edge of the mattress, lift edge of
sheet that is hanging to form a triangle and lay
5 4 3 2 1 REMARK
upper part of sheet back onto bed

Tuck the lower hanging section under the
mattress
Repeat for each corner
Tuck the sides of the sheet under the mattress
PROCEDURE
Fold the draw sheet in half
Identify the center of the draw sheet and place
it close to the client
Fan-fold or roll-draw sheet closest to the client
and tuck under soiled linen
Smooth linen
Add protective padding if needed
Tuck draw sheet under mattress, working from
the center to the edges
Draw sheet should be positioned under the
lower back and buttocks
11 Log roll client over onto side facing you.
Raise side rail
12 Move to other side of bed
Remove soiled linens by rolling into a bundle
and place in linen hamper without touching
uniform
13. Unfold/unroll bottom sheet, then draw sheet
Look for objects left in the bed
Grasp each sheet with knuckles up and over
the sheet and pull tightly while leaning back
with your body weight
Client may be positioned supine
14 Place top sheet over client with center of sheet in
middle of bed
Unfold top of sheet over client
Remove bath blanket left on client to prevent
exposure during bed making
Place top blanket over client, same as the top
sheet
15. Raise foot of mattress and tuck the corner of the top
sheet and blanket under
Mitter the corner
Repeat with other side of mattress
16 Grasp top sheet and blanket over clients toes and pull
upward, then make a small fan-fold in the sheet
10
5 4 3 2 1 REMARK
17. Remove soiled pillowcase

Grasp center of clean pillowcase and invert
pillowcase over hand or arm
Maintain grasp of pillowcase while grasping
center of pillow
Use other hand to pull pillowcase down over
pillow
18
19
PROCEDURE
Place pillow under clients head
While changing pillowcase, client can be
instructed to rest head on bed, or place a
blanket under clients head
Document procedure used to change linens and
clients condition during the procedure
Remove gloves and wash hands.
Date:_____
5 4 3 2 1 REMARK
Date:__________
COLLEGE OF NURSING
SAFE WALKING
PROCEDURE
5 4 3 2 1 REMARK
Identify client. Introduce self and explain the procedure
Elevate the head of the bed and wait for several

minutes
Lower the bed height
With one arm on the clients back and one arm under
the clients upper legs, move the client into the
dangling position.
Encourage the client to dangle at side of the bed for
several minutes
Place gait belt around clients waist ; secure the buckle
in front
Stand in front of client with your knees touching the
clients knees
Place arms under clients axilla.
Assist client to a standing position, allowing client time
to balance
Help the client ambulate the desired distance or
distance of tolerance by placing your hand under the
clients forearm and ambulating close to the client
Help the client back to the bed or chair.
Make the client comfortable and make sure all lines
and tubes are secure
Document the activity
Wash hands.
3
4
5
6
7
8
9
10
11
12
13
14
Date:_____
Date:__________
COLLEGE OF NURSING
ASSISTING WITH CRUTCHES, CANE OR WALKER
ASSISTIVE DEVICES
A. CRUTCH WALKING
1
2
3
4
5
6
PROCEDURE
Identify the client. Introduce yourself and explain the
procedure ( that you will be assisting with ambulation
using crutches)
Assess client for strength, mobility, range of motion,
visual acuity, perceptual difficulties and balance
(collaborate with the physical therapist)
Adjust crutches to fit the client.
With the client supine, measure from the heel
to the axilla
With the client standing, set the crutch position
at a point 4 to 5 inches lateral to the client and
4 to 6 inches in front of the client
The crutch pad should fit 1.5 to 2 inches below
the axilla (3 finger width)
The hand grip should be adjusted to allow for
the client to have elbows bent at 30 degrees
flexion
Lower the height of the bed.
Dangle the client at the side of the bed for several
minutes
Assess for vertigo
Instruct client on method to hold the crutches: that is,
with elbows bent 30 degrees and pad 1.5 to 2 inches
below the axilla
Instruct client to position crutches lateral to and
5 4 3 2 1 REMARK
forward of feet.
Demonstrate correct positioning
Apply the gait belt around the clients waist if balance
7
and stability are unreliable
8
Assist the client to a standing position with crutches.
Stand close to the client to support as needed
Document procedure and the clients condition during
9. the procedure
10. Wash hands
COLLEGE OF NURSING
ASSISTIVE DEVICES
a.1 FOUR POINT GAIT
5 4 3 2 1 REMARK
PROCEDURE
Position the crutches 4.5 to 6 inches to the side
and in front of each foot
Move the right crutch forward 4 to 6 inches and
move the left foot forward even with the left
crutch
Move the left crutch forward 4 to 6 inches and
move the right foot forward, even with the right
crutch.
Repeat the four point gait
a.2 THREE POINT GAIT
Advance both crutches and the weaker leg
forward together 4 to 6 inches.
Move the stronger leg forward, even with the
crutches
Repeat the three point gait
a.3 TWO POINT GAIT
Move the left crutch and right leg forward 4 to 6
inches
Move the right crutch and left leg forward 4 to 6
inches
Repeat the two point gait
a.4 SWING THROUGH GAIT
Move both crutches forward together 4 to 6

inches
Move both legs forward together in a swinging
motion, even with the crutches
Repeat the swing through gait
Date:_____
Date:__________
COLLEGE OF NURSING
ASSISTIVE DEVICES
WALKING UP STAIRS
PROCEDURE
Stand beside and slightly behind the client.
Instruct client to position the crutches as if
walking
Place body weight on hands
Place the strong leg on the first step
Pull the weak leg up and move the crutches up
to the first step
Repeat for all steps
WALKING DOWN THE STAIRS

PROCEDURE
Position the crutches as if walking
Place weight on the strong leg
Move the crutches down to the next lower step
Place partial weight on hands and crutches
Move the weak leg down to the step with
crutches
Put total weight on arms and crutches
Move strong leg to same step as weak leg and
crutches
Repeat for all steps
A second caregiver standing behind the client
5 4 3 2 1 REMARK
2
3
4
holding on to the gait belt will further decrease

the risk of falling
. Consult with physical therapist for clients learning to
walk with crutches
Wash hands
the procedure
Date:_____
Date:__________
COLLEGE OF NURSING

ASSISTIVE DEVICES
b.WALKING WITH A CANE
1
2
3
4
5
6
7
8
PROCEDURE
Identify the client, introduce self and explain the
procedure
Lower the height of the bed
minutes
visual acuity, perceptual difficulties and balance. Note:
coordinate with the physical therapy
Apply the gait belt around the clients waist if balance
and stability are unreliable
Have the client hold the cane in the hand opposite the
affected leg.
Explain the safety and body mechanics
underlying using the cane on the strong side
Have the client push himself up from the sitting
position while pushing down on the bed with his arms
Have the client stand at the bedside for a few minutes
Assess the height of the cane
With the cane placed 6 inches ahead of the
clients body, the top of the cane should be at
wrist level with the arm bent 25% to 30% at the
5 4 3 2 1 REMARK
elbow
9
10
2
3
4
5
1
2
3
4
5
6
7
8
9
Walk to the side and slightly behind the client, holding

the gait belt if needed for stability
THE CANE GAIT
Move the cane and the weaker leg forward at
the same time for the same distance
Place weight on the weaker leg and the cane
Move the strong leg forward
Place weight on the strong leg
b.1 SITTING WITH A CANE

PROCEDURE
Have client turn around and back up to the chair.
Have the client grasp the arm of the chair with
the free hand and lower self into the chair
Bes sure to place the cane out of the way but
within reach
Set realistic goals and opportunities for progressive
ambulation using a cane
Consult with a physical therapist for clients learning to
walk with a cane
Wash hands
the procedure
c. WALKING WITH A WALKER
PROCEDURE
Identify the client, introduce self and explain the
procedure
Lower the height of the bed
minutes. Assess the vertigo
Provide a robe or other covering and shoes with firm,
nonslip soles
visual acuity, perceptual difficulties, and balance
Apply gait belt around the clients waist if balance and
stability are unreliable
Place the walker in front of the client
Have the client push himself up from the sitting
position while pushing down on the bed with his arms
Have the client transfer his hands to the walker
handgrips, one at a time
5 4 3 2 1 REMARK
10
11
Be sure the walker is adjusted so the handgrips are

just below waist level and the clients arms are slightly
bent at the elbow
Walk to the side and slightly behind the client, holding
the gait belt if needed for stability
WALKER GAIT
PROCEDURE
Move the walker and the weaker leg forward at
the same time
Place as much weight as possible or as
allowed on the walker leg, using the arms for
supporting the rest of the weight
Move the strong leg forward and shift the
weight to the strong leg
c.1 SITTING WITH A WALKER
Have the client turn around in front of the chair
and back up until the back of the legs touch the
chair
Have him place his hands on the chair
armrests, one hand at a time
Then lower self into the chair using the arm
rests for support
Set realistic goals and opportunities for
progressive ambulation using a walker
Consult with a physical therapist
Document procedure and the clients condition
during the procedure
Wash hands
Date:_____
5 4 3 2 1 REMARK
Date:__________
COLLEGE OF NURSING
ASSISTING CLIENT DURING MEAL TIME
1
2
3
4
5
6
7
8
9
PROCEDURE
Before bringing the meal tray into the room, ask
whether the client needs to void or have a bowel
movement
Provide hygiene measures before serving the meal
tray
Position the client in a comfortable position, preferably
in a chair, if not contraindicated
Ask about the clients eating habits and the foods the
client prefers to eat first
Ask what need is needed
Make sure the foods are being served at the correct
temperature
Provide assistance if the client is unable to handle
eating utensils or open containers and packages
Provide adequate time for the client who has difficulty
in chewing or swallowing.
Make sure that someone is in the room while
the client is eating
Document the type and amount of food taken at each
meal
Remove the tray after the meal and provide hygiene
measures
5 4 3 2 1 REMARK
Date:_____
Date:__________

Checkist For NCM 100 (Skills)

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COLLEGE OF NURSING

PERFORMANCE EVALUATION TOOL

Assist client to assume a comfortable position

Offer a mirror to the client for viewing himself/herself

PERFORMANCE EVALUATION TOOL

Follow steps 19 t0 20 for brushing the patients teeth

Let the feet and fingernails soak for 20 to 30 minutes.

PERFORMANCE EVALUATION TOOL

Perform eye care (follow eye care procedure)

PERFORMANCE EVALUATION TOOL

lifting the mattress and rolling soiled linens to

upper part of sheet back onto bed

17. Remove soiled pillowcase

Identify client. Introduce self and explain the procedure

Elevate the head of the bed and wait for several

Move both crutches forward together 4 to 6

WALKING DOWN THE STAIRS

holding on to the gait belt will further decrease

PERFORMANCE EVALUATION TOOL

Walk to the side and slightly behind the client, holding

b.1 SITTING WITH A CANE

Be sure the walker is adjusted so the handgrips are

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