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Makes an Occupied Bed (Client Does Not Need Assistance to Turn) 1. Explain procedure 2. Provide privacy 3. Lower head of bed 4. Client is covered while linens are changed 5. Loosens top linen from the end of the bed 6. Raises side rail on side of bed to which client will move and client moves toward side of raised rail 7. Loosen bottom used linen on working side and move bottom used linen toward center of bed 8. Place and tuck in clean bottom linen or fitted bottom sheet on working side and tucks under client 9. Client moves back onto clean linen 10. Raise side rail and go to other side of bed 11. Remove used bottom linen 12. Pull and tuck in clean bottom linen, finish with bottom sheet free of wrinkles 13. Client is covered with clean top sheet and bath blanket/used top sheet has been removed 14. Change pillowcase 15. Linen is centered and tucked at foot of bed 16. Avoid contact between clothing and used linen 17. Dispose of used linen into soiled linen container and avoid putting linen on floor 18. Call light is within reach 19. Wash hands Measures and Records Blood Pressure 1. Explain procedure 2. Wipe bell/diaphragm and ear pieces with alcohol 3. Position client’s arm with palm up and upper arm is exposed 4. Feel for brachial artery 5. Place blood pressure cuff snugly on client’s upper arm, with sensor/arrow over brachial arty site 6. Earpieces are in ears and bell is over brachial artery site 7. Inflate cuff between 160-180 mm Hg 8. Deflate cuff slowly and note first sound and last sound 9. Call light is within reach 10. Wash hands 11. Record both systolic and diastolic pressures each within plus or minus 8mm of evaluator’s reading Measures and Records Urinary Output 1. Put on clean gloves 2. Pour contents of bedpan into measuring container without spilling or splashing urine outside of container 3. Measure the amount of urine at eye level with container on flat surface 4. Empty contents of measuring container into toilet 5. Rinse measuring container and pour rinse into toilet 6. Rinse bedpan and pour rinse into toilet 7. Remove and dispose of gloves into waste, wash hands 8. Record contents of container within plus or minus 25 ml/cc of evaluator’s reading Performs Passive Range of Motion For One Knee and One Ankle 1. Explains procedure 2. Provide privacy 3. Instruct client to inform nurse aide if pain is experienced during exercise 4. Support leg at knee and ankle while performing range of motion for knee 5. Bend the knee and ten return leg to client’s normal position (extension/flexion) AT LEAST THREE TIMES unless pain is verbalized 6. Support foot and ankle close to the bed while performing range of motion for ankle 7. Push/pull foot toward head (dorsiflexion) and push/pull foot down, toes point down (plantar flexion) AT LEAST THREE TIMES unless pain is verbalized 8. While supporting the limb, moves joints gently, slowly, and smoothly through the range of motion, discontinuing exercise if client verbalizes pain 9. Call light is within reach 10. Wash hands Performs Passive Range of Motion For One Shoulder 1. Explain procedure 2. Provide privacy 3. Instruct client to inform nurse aide if pain is experienced 4. Support client’s arm at elbow and wrist while performing range of motion for shoulder 5. Raise client’s straightened arm from side position upward toward head to ear level and return arm down to side of body AT LEAST THREE TIMES unless pain is verbalized 6. Move client’s straightened arm away from the side of the body to shoulder level and returns to side of body AT LEAST THREE TIMES unless pain is verbalized 7. While supporting the limb, moves joint gently, slowly, and smoothly through the range of motion, discontinuing exercise if client verbalizes pain 8. Call light is within reach 9. Wash hands Positions on Side 1. Explain procedure 2. Provide privacy 3. Lower head of bed 4. Raise side rail on side to which body is to be turned 5. Slowly roll onto side as one unit toward raised side rail 6. Place or adjust pillow under head for support 7. Client is positioned so that client is not lying on arm 8. Support top arm with supportive device 9. Place supportive device between legs with top knee flexed; knee and ankle supported 10. Call light is within reach 11. Wash hands