Nursing Skills Clinical Action Checklist

NATIONAL ENGLISH CENTRE
Registered in Ministry of National Education

No. 029/PLSM/JT/IX/2003
SK. DIKMEN No. 157/1.851.4
Nursing Skills
Clinical Action Checklist
- Washing Hands -
No. Items
a. Preparation Stage
1. Prepare supplies and materials; soap, single use towel or toilet paper, running water
2. Remove hands and wrist accessories
3. Roll up sleeves
4. Turn on the water tap
5. Wet hands
6. Turn off the water tap
7. Apply soap and lather thoroughly
b. Main Stage
1. Rub hands palm to palm in circular motion
2. Rub right palm over left dorsum with fingers interlaced and vice versa
3. Rub hands palm to palm with fingers interlaced
4. Rub backs of fingers to opposing palms with fingers interlocked
5. Rub rotationally left thumb clasped in right palm and vice versa
6. Rub rotationally right fingertips on left palm and vice versa
c. Finishing Stage
1. Turn on the water tap
2. Rinse hands in down position, elbow straight
3. Turn off the water tap using elbow or toilet paper
4. Dry hands completely using single use towel or toilet paper
National English Centre – Bandung Branch

Jl. Rancabolang No. 53 Manjahlega, Rancasari Bandung - Jawa Barat Telp. (022) 7567390
Email : necbandung@gmail.com; Website : www.nec-institute.com
SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Applying Medical Gloves -
No. Items
1. Remove hand accessories
2. Choose the right size of the gloves
3. Wash and dry hands
4. Peel the gloves package
5. Identify the gloves position
6. Start applying glove on your dominant hand (e.g. right)
7. Pinch the cuff of left glove using thumb and two fingers
8. Point the right fingertips
9. Slide the fingers according to the space of the glove
10. Raise the right hand
11. Gently pull the glove
12. Slide your fingers under the cuff of left glove with abducted thumb
13. Point your left fingertips
14. Slide the fingers according to the space of the glove
15. Raise the left hand
16. Gently pull the glove
17. Interlace the gloved hands

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Checking Vital Signs -
No. Items
a. Checking Blood Pressure
1. Wash hands
2. Gather all equipment
3. Cleanse stethoscope earpieces and diaphragm
4. Identify patient and introduce yourself
5. Ask for patient’s condition
6. Mention your action along with its purposes
Have the patient rest at least 5 minutes before measurement. Have the patient rest at least 5
7.
minutes before measurement
8. Determine previous baseline blood pressure of patient while waiting
9. Identify factors likely to interfere which accuracy of blood pressure measurement
10. Assist patient to comfortable position
11. Ask patient to roll up the sleeve
12. Put on the stethoscope
13. Apply the cuff above the brachial artery for 3 fingers range
14. Attach the manometer on the cuff and make sure it is shown in zero
15. Fasten the valve clockwise
16. Check the stethoscope diaphragm
17. Locate the radial and brachial pulse
18. Put the stethoscope diaphragm under the cuff and on the brachial artery
19. Put your left index, middle, and ring finger on patient’s radial artery
Squeeze the bulb until the manometer shows the appropriate scale (until the radial artery
20.
stops)
Look at the manometer and listen to the pulse while releasing the valve counter clockwise
21.
slowly
22. The first pulse you hear is called systolic pressure
23. The last pulse you hear is called diastolic pressure
24. Put off the cuff and the stethoscope
25. Tell the patient that the procedure is done and inform the result to her
26. Make documentation in SOAP form on the Objective Section
27. Tidy up all equipment
b. Checking Radial Pulse
1. Straighten the patient’s right/left hand and make sure the patient feels comfortable and calm
Place your index and middle fingers on inner aspect of patient’s wrist over the radial artery
2.
and apply light but firm pressure until pulse is felt/palpated
3. Identify pulse rhythm
4. Count pulse rate by using second hand on watch in one minute
c. Checking Respiratory Rate
1. Look carefully at the movement of patient chest
2. Identify respiration rhythm
3. Count respiratory rate in on minute

SK. DIKMEN No. 157/1.851.4
d. Checking Oral Temperature Using Glass Thermometer

1. Position the client in a sitting or lying position with the head of the bed elevated 45° to 60°
2. Take the blue tip of thermometer
3. Use a tissue to dry thermometer from bulb’s end toward fingertips
Read thermometer by locating mercury level. It should read 35.5°C (96°F). If thermometer
is not below normal body temperature reading, grasp thermometer with thumb and
4.
forefinger and shake vigorously by snapping the wrist in a downward motion to move
mercury to a level below normal
Place thermometer in client’s mouth under the tongue and along the gum line to the
5.
posterior sublingual pocket
6. Instruct client to hold lips closed
7. Leave in place for 3-5 minutes
8. Remove thermometer and wipe with tissue away from fingers toward the bulb’s end
9. Read at eye level and rotate slowly until mercury level is visualized.
Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold
10.
water, and return to storage container.
11. Remove and dispose of gloves in receptacle. Wash hands

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Positioning Patient in Bed -
No. Items
a. Supine to Side-Lying
1. Wash hands.
2. Explain procedure to client.
3. Gather all necessary equipment.
4. Adjust bed to comfortable working height.
5. Lower side rail on side of bed from which you are assisting client.
6. Follow proper body mechanics guidelines.
7. Slide your hands underneath the client.
Move the client to one side of the bed by lifting the client’s body toward you in stages:
- first the upper trunk
8. - then the lower trunk
- and finally the legs.
(Lift the client’s body; do not drag the client across the sheets.)
Place the client’s inside arm next to the client’s body with the palm of the hand against the
9.
hip.
10. Cross the client’s outside arm and leg toward midline
11. Log roll the client toward you using the client’s outside shoulder and hip
12. Place pillows to support the client’s head and arms
If necessary, place pillows to support:
- the topside leg,
13.
- fully and equally the thigh, knee, ankle, and foot
- the back
b. Side-Lying to Prone
1. Remove positioning towels, pillows, or other support devices
Assess whether the client’s position in bed needs to be adjusted to accommodate the continued
2.
movement into prone
3. Move the client’s inside arm next to the client’s body with palm against hip
4. Roll the client onto the stomach using the shoulder and hip as key points of control
Place the head in a comfortable position to one side without excessive pressure to sensitive
5.
areas
6. Place pillows under the trunk as needed to relieve pressure and increase comfort
7. Place the client’s arms comfortably at the client’s side
8. Uncross the legs with the feet approximately a foot apart
9. Use a shallow pillow or a folded towel to support the client’s head comfortably
10. Place a pillow under the abdomen to support the back
If necessary, place additional pillow under the lower leg to reduce the pressure of the toes and
11.
forefoot against the bed
c. Prone to Supine
1. Remove positioning towels, pillows, or other supporting devices.
2. Slide your hands underneath the client.
3. Move the client segmentally to one side of the bed to accommodate the new position.

SK. DIKMEN No. 157/1.851.4
4. Position the inside arm next to the client’s body with the client’s palm next to the hip.
Roll the client to supine by log rolling the client toward you using the client’s outside shoulder
5.
and hip for leverage.
Have the client’s face positioned away from the direction of the roll to prevent undue pressure
6.
to the face or neck.
When the client reaches supine, uncross the client’s arms and legs and place them comfortably
7.
into anatomical positions.
8. Use a footboard to support the foot as well as heel protectors may be used.
Place a pillow placed between the heel and gastrocnemius muscle to reduce the pressure on
9.
the heels
10. Use a trochanter roll to prevent excessive external rotation of the lower extremity
11. For comfort, use additional pillows to support the client’s head, arms, or lower back
12. Be sure to replace side rails to upright position as well as lower bed to beginning position.
13. Place call light within reach of the client
14. Move bedside table close to bed and place items of frequent use within reach of the client

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Making Occupied Bed -
No. Items
1. Wash and dry hands.
2. Explain procedure to client.
3. Prepare equipment and bring them to the bedside.
4. Put on curtain to provide privacy.
5. Remove top sheet and blanket.
6. Loosen bottom sheet at foot and sides of bed.
7. Lower side rail nearest the nurse, if necessary for access.
8. Position client on side, facing away from you.
9. Reposition pillow under head.
10. Fan-fold or roll bottom linens close to client toward the center of the bed.
11. Smooth wrinkles out of mattress.
12. Place clean bottom linens with the center fold nearest the client.
13. Fan-fold or roll clean bottom linens nearest client and tuck under soiled linen.
14. Maintain an adequate amount of sheet at head and foot of bed for tucking.
15. Miter bottom sheet at head of bed, then at foot of bed.
16. Fold the draw sheet in half.
17. Identify the center of the draw sheet and place it close to the client.
18. Fan-fold or roll draw sheet closest to client and tuck under soiled linen.
19. Add protective padding if needed.
20. Tuck draw sheet under mattress, working from the center to the edges.
21. Draw sheet should be positioned under the lower back and buttocks.
22. Log roll client over onto side facing you.
23. Raise side rail.
24. Move to other side of bed.
Remove soiled linens by rolling into a bundle and place in linen hamper without touching
25.
uniform.
26. Unfold/unroll bottom sheet; then draw sheet.
27. Look for objects left in the bed.
Grasp each sheet with knuckles up and over the sheet and pull tightly while leaning back
28.
with your body weight.
29. Client may be positioned supine.
30. Place top sheet over client with center of sheet in middle of bed.
31. Unfold top of sheet over client.
32. Place top blanket over client, same as the top sheet.
33. Raise foot of mattress and tuck the corner of the top sheet and blanket under.
34. Miter the corner. Repeat with other side of mattress
Grasp top sheet and blanket over client’s toes and pull upward, then make a small fan-fold
35.
in the sheet.
36. Remove soiled pillowcase.
37. Grasp center of clean pillowcase and invert pillowcase over hand/arm.
38. Maintain grasp of pillowcase while grasping center of pillow.

SK. DIKMEN No. 157/1.851.4
39. Use other hand to pull pillowcase down over pillow.

40. Place pillow under client’s head.
While changing pillowcase, client can be instructed to rest head on bed, or place a blanket
41.
under client’s head.
42. Document procedure used to change linens and client’s condition during the procedure.

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Transferring Patient from Bed to Wheelchair -
No. Items
1. Inform client about desired purpose and destination
Assess client for ability to assist with the transfer and for presence of cognitive or sensory
2.
deficits
3. Lock the bed in position
4. Place any splints, braces, or other devices on the client
5. Place the client’s shoes or slippers on the client’s feet
6. Lower the height of the bed to lowest possible position
7. Slowly raise the head of the bed if this is not contraindicated by the client’s condition
8. Place one arm under the client’s legs and one arm behind the client’s back
Slowly pivot the client so the client’s legs are dangling over the edge of the bed and he is in
9.
a sitting position on the edge of the bed
10. Allow client to dangle for 2–5 minutes. Help support client if necessary
Bring the chair or wheelchair close to the side of the bed. Place it at a 45° angle to the bed. If
11.
the client has a weaker side, place the chair or wheelchair on the client’s strong side
12. Lock wheelchair brakes and elevate the foot pedals
13. If you will be using a gait belt to assist the client, place it around the client’s waist
14. Assist client to side of bed until feet are firmly on the floor and slightly apart
Grasp the sides of the gait belt or place your hands just below the client’s axilla. Using a wide
15.
stance, bend your knees and assist the client to a standing position
16. Standing close to the client, pivot until the client’s back is toward the chair
Instruct the client to place hands on the arm supports, or place the client’s hands on the arm
17.
supports of the chair
18. Bend at the knees, easing the client into a sitting position
19. Assist client to maintain proper posture. Support weak side with pillow if needed.
Secure the safety belt, place client’s feet on feet pedals, and release brakes if you will be
moving the client immediately. Make sure tubes and lines, arms, and hands are not pinched
20.
or caught between the client and the chair. If the client is sitting in a chair, offer a footstool if
available

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Administering Subcutaneous Injection -
No. Items
1. Wash and dry your hands.
2. Apply sterile gloves
3. Clean the rubber diaphragm of the vial with alcohol wipe.
4. Discard the wipe into the kidney bowl.
5. Remove the cap of the needle.
6. Put the vial upside down in an eye-level.
7. Without touching the needle, insert needle through vial diaphragm.
8. Slowly pull down on the plunger to take the medication into the syringe.
9. Pull the needle out of the vial.
10. Put on the cap of the needle
11. Change the needle
12. Hold the syringe vertically and flick the barrel with fingernail.
Carefully depress the plunger to push out the air into the first drop of medication comes out
13.
of the needle.
14. Rotationally clean injection site with alcohol wipe once.
15. Let the alcohol dry and discard the alcohol wipe into the kidney bowl.
16. Insert the needle to the skin at 45 degrees angle.
Gently pull back on the plunger to make sure that the tip of the needle is not in the blood
vessel. If blood appears in the syringe, pull the needle out and discard the syringe, needle,
17.
and medication into kidney bowl then start the process again using new medication, syringe,
and needle.
18. Slowly inject the medication.
19. When all the medication is injected, pull the needle out of the skin
20. Discard the needle and its cap into the kidney bowl.
21. Tidy up supplies.
22. Wash and dry your hands.

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Performing Vulva Hygiene -
No. Items
1. Prepare supplies
2. Prepare room, and close curtain, window, and door
3. Wear apron, wash hands in running water and dry them with clean towel
4. Assist patient to put off her lower cloth carefully
Put waterproof layer underneath patient buttock carefully while asking the patient to turn
5.
her body right and left
6. Position the patient in dorsal recumbent by bending and widen her knees
7. Bring supplies near to the patient
8. Apply sterile or clean gloves and take anal 5 cleansing wipes or as necessary
Clean right labia major (farthest part) using wipes with thumb and discard the wipes to
9.
kidney bowl
Clean left labia major (closest part) using wipes with thumb and discard the wipes to kidney
10.
bowl
Clean right labia minor (farthest part) using wipes with thumb and discard the wipes to
11.
kidney bowl
Clean left labia minor (closest part) using wipes with thumb and discard the wipes to kidney
12.
bowl
Clean the upper part of Mons pubis to anus using wipes with thumb and discard the wipes to
13.
kidney bowl
14. Tidy up and decontaminate all supplies in 0.5 chlorine
15. Assist patient to put on her lower cloth
16. Put off apron, wash hands in running water, and clean them with clean towel
17. Explain to the patient that the procedures have been all done

SK. DIKMEN No. 157/1.851.4
Nursing Skills
- Helping Choking Baby -
No. Items
1. Pick the baby up
2. Turn the baby into backside position
3. Mildly tap the baby’s back five times (back slap)
4. Turn the baby into side-lying position
5. Check the baby’s mouth for some substances using little finger
6. If the steps don’t work, turn the baby into upside position
Use index and middle fingers to push the baby’s chest five times with the interval of three
7.
seconds each (Chest thrust)
8. Turn the baby into side-lying position
9. Check again the baby’s mouth
10. If the steps don’t work as well, Repeat the steps and call medical expert


Nursing Skills Clinical Action Checklist

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NATIONAL ENGLISH CENTRE

Registered in Ministry of National Education

National English Centre – Bandung Branch

National English Centre – Bandung Branch

National English Centre – Bandung Branch

d. Checking Oral Temperature Using Glass Thermometer

National English Centre – Bandung Branch

National English Centre – Bandung Branch

National English Centre – Bandung Branch

National English Centre – Bandung Branch

39. Use other hand to pull pillowcase down over pillow.

National English Centre – Bandung Branch

National English Centre – Bandung Branch

National English Centre – Bandung Branch

National English Centre – Bandung Branch

National English Centre – Bandung Branch

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