Nurse Assisting
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Chapter 18 Expanded Skills

Click on the skills to review expanded skills discussed in this chapter.

Starting-Up Steps

  1. Knock before entering, identify the client, and introduce yourself.
  2. Complete hand hygiene.
  3. Provide for privacy.
  4. Explain to the client what you will be doing before you start doing it.
  5. Assemble your supplies.
  6. Ensure that the bed is at a good working height and is locked; or, if the bed is not in use, you are in an ergonomically correct position to assist the client.

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Taking a Rectal Temperature With a Digital Thermometer

When: ​Take a client’s temperature on the scheduled bath day, per the facility’s routine, or during an episodic illness when delegated by the nurse.

Why: ​A temperature outside the normal range can indicate illness.

What: ​Supplies needed for this skill include:

  • Gloves
  • Digital thermometer labeled for rectal use only
  • Sheath, if available
  • Water-based lubricant
  • Alcohol wipes

How:

  1. Complete your starting-up steps.
  2. Place an extra paper towel on the overbed table for the lubricating jelly.
  3. Raise one side rail. Position yourself and your supplies on the opposite side of the bed where the side rail is not raised.
  4. Squeeze a small amount of lubricant onto a paper towel.
  5. If plastic sheaths are not used with the thermometer, clean the stem of the thermometer (the end that is inserted into the client’s rectum) with an alcohol wipe. Discard the wipe into the wastebasket. If plastic sheaths are used with the thermometer, cover the thermometer with the sheath. Don gloves.
  6. Ask the client to roll over onto their side. Assist the client if they are unable. Fanfold the top bed linens to below the client’s buttocks. Adjust the client’s gown or pajama bottoms to expose only their buttocks.
  7. Dip the tip of the thermometer into the lubricant that was squeezed onto the paper towel, rolling the tip so that it is covered by the lubricant.
  8. Turn on the thermometer by pressing the colored button on its top. Verify that the thermometer is on. The thermometer screen will read “low,” or display the ambient temperature.
  9. Explain the procedure to the client and ask them to relax as much as possible. With one hand, spread the buttocks apart. With your opposite hand, insert the thermometer into the rectum approximately 1 inch. Hold the thermometer in place until it beeps, then remove it from the rectum. Obtain the temperature from the thermometer’s screen.
  10. If the temperature is out of normal limits, retake the temperature by repeating Steps 8–9.
    1. You must turn off the thermometer and then turn it back on to clear the original reading.
    2. If you feel the temperature reading was in error due to client noncompliance with placement, you may want to use a different method of taking the temperature, such as the axillary method.
  11. If the temperature is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
  12. If a sheath was used, remove and discard it into the wastebasket. Clean the stem of the thermometer with an alcohol wipe and discard the wipe into the wastebasket.
  13. Record the results.
  14. Complete your finishing-up steps.

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Taking Blood Pressure With an Electronic Wrist Cuff

What: Supplies needed for this skill include:

  • Electronic wrist cuff

How:

  1. Complete your starting-up steps.
  2. Ask the client to sit with their legs and ankles uncrossed. If the client is in bed, raise the head of the bed to a high-Fowler’s position.
  3. Ask the client to insert their wrist though the wrist cuff. Fasten the Velcro around the wrist cuff.
  4. Ask the client to place their wrist across their chest, at the level of their heart, palm against the chest. Instruct them not to move or talk during the measurement.
  5. Record the results.
  6. Complete your finishing-up steps.

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Taking Blood Pressure With an Electronic Arm Cuff

What: Supplies needed for this skill include:

  • Electronic arm cuff

How:

  1. Complete your starting-up steps.
  2. Select an appropriate size cuff for your client. Change the cuff as necessary by detaching the current cuff and inserting the tubing of the desired cuff into the machine.
  3. Ask the client to sit with their legs and ankles uncrossed. If the client is in bed, raise the head of the bed to a high-Fowler’s position.
  4. Remove the client’s arm from their sleeve to expose the antecubital and upper arm area. If the client is wearing a short-sleeve shirt, push the sleeve up to their shoulder.
  5. Support the client’s arm so that the upper arm is resting at the level of their heart. This can be done by physically holding the arm with your nondominant hand, positioning with pillows, or placing the arm on the overbed table.
  6. Ask the client to insert their hand through the arm cuff. Position the arm so that the palm is facing upward. Move the cuff up above their elbow.
  7. Fasten the Velcro so that the cuff is snug on the client’s arm. You should be able to fit at least one finger between the cuff and the client’s arm. The bottom edge of the cuff should be approximately 1 inch above the bend of their arm.
  8. With your dominant index and middle fingers, palpate the brachial artery, which is found in the medial aspect of the antecubital area. Place the white mark on the bottom edge of the cuff over the brachial artery.
  9. Instruct the client not to move or talk during the measurement.
  10. Press the “Start” button. Allow the cuff to inflate automatically. The cuff will inflate and then begin to deflate until the blood pressure is determined.
  11. Once the cuff is completely deflated, obtain the blood pressure reading from the screen.
  12. If the blood pressure is out of normal limits, allow the client to rest for 3–5 minutes and retake it by repeating Steps 5–11.
  13. If the blood pressure is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
  14. Lower the head of the bed, if applicable.
  15. Record the results.
  16. Complete your finishing-up steps.

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Obtaining and Recording Orthostatic Blood Pressures

What: Supplies needed for this skill include:

  • Electronic wrist cuff or arm cuff, or stethoscope and sphygmomanometer
  • Alcohol wipes
  • Gait belt

How: 

  1. Complete your starting-up steps.
  2. The client should be lying flat, in a supine position. Ensure that they have been lying down for at least 5 minutes.
  3. Complete the blood pressure measurement. Record the results on a piece of paper or on the flow chart if it is in the client’s room.
  4. Assist the client to dangle on the side of the bed. Allow the client to dangle for 3 minutes.
  5. Support the client’s arm so that it is resting flat on the overbed table, at the level of their heart.
  6. Complete the blood pressure measurement. Record the results on a piece of paper or on the flow chart if it is in the client’s room.
  7. Place a gait belt around the client. Assist the client to a standing position.
  8. Allow the client to use any assistive devices such as a cane or walker for stabilization. Assist the client to stand for 3 minutes, or as long as they can tolerate if they cannot stand for 3 minutes.
  9. If necessary, ask another nursing assistant to steady the client and hold on to the gait belt while you take the next measurement.
  10. Support the client’s arm so that their lower arm and hand are tucked and stabilized under your nondominant arm, at the level of their heart.
  11. Complete the blood pressure measurement.
  12. Record the results on a piece of paper, or on the flow chart if it is in the client’s room.
  13. If the blood pressure is out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
  14. Record the results, if you haven’t already done so.
  15. Complete your finishing-up steps.

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Weighing a Client in Bed

When: Measure a client’s weight on the scheduled bath day or during an episodic illness when delegated by the nurse.

Why: A fluctuation in weight can indicate illness, malnutrition, or overeating habits.

What: Supplies needed for this skill include

  • Bed scale

How:

  1. Complete your starting-up steps.
  2. Zero the bed scale.
  3. Assist the client into the bed. Excessive linens on the bed should be avoided.
  4. Standing away from the bed press the weight button found on the bed.
  5. Make a note of the client’s weight.
  6. Complete your finishing-up steps.

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Measuring Height of a Client in Bed

When: Measure a client’s height upon admission to the facility.

Why: The height measurement provides baseline information and is useful when determining medication amounts and dietary considerations.

What: Supplies needed for this skill include

  • Bath blanket
  • Tape measure

How:

  1. Complete your starting-up steps.
  2. Ask or assist the client to move onto their side. Use a second nursing assistant if the client needs assistance.
  3. Place a bath blanket flat under the client. Assist the client back to the prone position.
  4. Make a mark on the bath blanket at the foot and the top of the head.
  5. Ask or assist the client to move back onto their side.
  6. Remove the bath blanket. Assist the client back to the prone position.
  7. Place one end of the tape measure at one mark on the bath blanket and stretch taut to the second mark. This is the client’s height.
  8. Document the height per the facility policy.
  9. Complete your finishing-up steps.

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Counting Heart Rate—Apical Pulse

When: Take a client’s pulse on the scheduled bath day, per the facility’s routine, during an episodic illness, or when delegated by the nurse.

Why: A heart rate outside the normal range can indicate illness or injury.

What: Supplies needed for this skill include

  • Stethoscope
  • Alcohol wipes

How:

  1. Complete your starting-up steps.
  2. Locate the apical pulse. This is found under the left breast area. Provide for privacy.
  3. Place a cleaned and warm stethoscope over the apical pulse.
  4. Ask the client to be still and not speak during this measurement.
  5. Count the pulse for one minute. Each “lub-dub” is one beat. If the heart rate is regular you may count for 30 seconds and then multiply by two for your beats per minute.
  6. Complete your finishing-up steps.

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Finishing-Up Steps

  1. Ensure that all of the client’s needs have been met and that the client is positioned as desired.
  2. See to safety. Replace any alarms or positioning devices, as indicated on the care plan or individual service plan. The bed is in the low position and is locked.
  3. Place the call light within easy reach.
  4. Clean and replace equipment, and return supplies to the designated place in the client’s room or facility storage area.
  5. Leave the room clean and in order. Ensure that the bed is made. Remove trash and dirty linens from the room.
  6. Complete hand hygiene.
  7. Report and document, as required by your facility.

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