Nurse Assisting
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Chapter 22 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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Applying a Condom Catheter

When: ​A condom catheter is used as ordered by the physician to collect urine noninvasively.

Why: ​Condom catheters may be used in lieu of an indwelling catheter to collect urine on an ongoing basis.

What: ​Supplies needed for this skill include:

  • Gloves
  • Condom catheter
  • Adult wipes
  • Bed protector
  • Bath blanket
  • Urinary drainage bag or bag

How:

  1. Complete your starting-up steps.
  2. The client should be lying in bed, on their back with the bed flat. Fanfold the bed linens to the client’s knees.
  3. Don gloves.
  4. If the client is wearing a hospital gown, pull it up slightly to expose the perineum. If the client is wearing pajama bottoms, lower them to their knees.
  5. If the bed protector under the client is soiled, remove and replace it with a clean one. Place the soiled bed protector in the linen bag. If there is no bed protector under the ­client, place one under them to protect the bed linens from becoming soiled.
  6. Cleanse the penis with adult wipes. Discard the wipes into the wastebasket. Allow the penis to air dry.
  7. Remove the condom catheter from the package.
  8. Hold the penis upright at a 90-degree angle with your nondominant hand. With your dominant hand place the condom catheter over the head of the penis and roll it down to the base of the penis.
  9. Affix the condom catheter with the adhesive strip enclosed in the package in a spiral ­fashion at the base of the catheter to secure it. Avoid constriction of the penis.
  10. Attach the urinary drainage bag or leg bag to the distal end of the catheter.
  11. Adjust the bed linens as necessary to cover the client and position them as desired.
  12. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  13. Complete your finishing-up steps.

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Administration of an Over-the-Counter Enema

When: ​An enema is administered typically if a client has not had a bowel movement for 5 days, or when ordered by the physician.

Why: ​An enema is given to alleviate constipation.

What: ​Supplies needed for this skill include:

  • Gloves
  • Bed protector
  • Incontinence product, as necessary
  • Water-based lubricant, if product is not prelubricated
  • Commode

How:

  1. Complete your starting-up steps.
  2. The client should be lying in bed, on their back with the bed flat. Fanfold the bedspread and blanket to the foot of the bed.
  3. Raise one side rail. Move to the opposite side of the bed where the side rail is not raised.
  4. Don gloves.
  5. If the bed protector under the client is soiled, remove and replace it with a clean one. Place the soiled bed protector in the linen bag. If there is no bed protector under the ­client, place one under them to protect the bed linens from becoming soiled.
  6. Ask the client to reach over himself, grab on to the side rail, and roll over so that they are on their left side. Assist them if they are unable. Ask the client to flex their right knee if possible.
  7. Adjust the top sheet as needed to ensure privacy. Only the buttocks should be exposed.
  8. Open the over-the-counter enema. Remove the cap and discard it into the wastebasket.
  9. If the product does not have lubrication, squeeze a small amount of lubricant onto a paper towel. Place the application tip of the enema into the lubricant, rolling the tip so it is covered by the lubricant.
  10. With your nondominant hand, spread the buttocks apart. With your dominant hand, insert the applicator tip of the enema into the rectum approximately 1 inch. Squeeze the bottle, rolling from the bottom upward, until all liquid is inside of the rectum, or until the client cannot hold any more of the liquid.
  11. Instruct the client to hold the contents of the enema in their rectum as long as possible.
  12. If the client is afraid of becoming incontinent, apply an incontinence garment.
  13. When they are ready, assist the client to the bedside commode or toilet as indicated on the care plan. If unable to get out of bed, place them on a bedpan.
  14. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  15. Lower the side rail.
  16. Complete your finishing-up steps.
  17. Record the results of the enema and report them to the nurse.

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Changing an Ostomy Appliance

When: ​An ostomy appliance should be changed on the scheduled appliance change day, or if the appliance is no longer adhering to the skin or is leaking.

Why: ​The appliance is changed to keep the client clean, the clothing clean, and the client and clothing free of odors, as well as to maintain the integrity of the skin under the appliance.

What: ​Supplies needed for this skill include:

  • Gloves
  • Adult wipes
  • Paper towels or towel
  • Bedpan
  • Protective barrier wipes
  • Ostomy pastes or powders, as desired by the client
  • Ostomy wafer
  • Ostomy pouch
  • Measuring device (stoma template) from appliance supply box
  • Scissors
  • Pen

How:

  1. Complete your starting-up steps.
  2. Don gloves.
  3. The client can be lying in bed, or in a sitting position, whichever they prefer.
  4. Expose the ostomy appliance.
  5. Keep the following items nearby throughout the procedure: adult wipes, bedpan, and wastebasket.
  6. Place paper towels or a towel under the ostomy pouch and on top of the client’s clothes or bed linens to prevent soiling.
  7. Remove the ostomy pouch from the ostomy wafer. Place the pouch in the wastebasket immediately.
  8. Remove the ostomy wafer by gently pulling the wafer away from the skin and pushing down on the skin at the same time. Discard this into the wastebasket.
  9. Cleanse the area surrounding the stoma with the adult wipes. Immediately discard the wipes into the wastebasket after use. Use as many wipes as needed to completely clean the area. You may also use washcloths and peri-cleanser if adult wipes are not available.
  10. Report any open or excoriated areas to the nurse for assessment prior to attaching a new wafer.
  11. Cleanse the entire area to be covered by the new ostomy wafer with the protective barrier wipes. Discard these into the wastebasket after use.
  12. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  13. Use the measuring device (stoma template) found in the appliance supply box to determine what size to cut the wafer. (The measuring device is a sheet of cardboard with holes of various sizes.)
    1. The size of the inner circle should be large enough to completely surround the stoma, yet not too large to expose the surrounding skin needlessly to feces—about 1/4 inch greater than the size of the stoma.
    2. Hold different holes over the stoma to determine what size wafer to cut.
  14. Once the appropriate size is determined, use your pen to draw the inner circle of the appropriate size on the back side of the wafer.
  15. With your scissors, cut out the wafer in the appropriate size. Discard the excess into the wastebasket.
  16. Don gloves.
  17. Prep the area to be covered by the wafer with powders or pastes, as the client prefers. This is optional. Check the client’s care plan for preferences, if they cannot communicate.
  18. Remove the paper backing from the wafer.
  19. Ensure that the skin is dry, and then place the wafer on the skin so that the hole of the wafer is centered evenly over the stoma.
  20. Gently press and massage the wafer on to the skin. The heat from your hands will warm the plastic and promote adherence of the wafer to the skin.
  21. Place the new ostomy pouch over the wafer, gently pressing all around the wafer, snapping the pouch into place. Ensure that the pouch is firmly fixed on the wafer to prevent leakage. If the pouch has a removable clamp, affix this to the bottom of the pouch to seal.
    1. Some ostomy pouches have Velcro® on the bottom. Simply fold the bottom of the pouch over to affix the Velcro®.
  22. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  23. Adjust the client’s clothing as necessary to cover the ostomy. Adjust the bed linens as necessary to cover the client.
  24. Complete your finishing-up steps.
  25. Record the bowel movement results, as indicated on the care plan.

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Assisting the Client With a Urinal

When: ​The nursing assistant assists the client to use a urinal when the client requests.

Why: ​A urinal is used by the male client who prefers it to using a bedpan, commode, or toilet.

What: ​Supplies needed for this skill include:

  • Gloves
  • Urinal
  • Bed protector
  • Washcloth, as necessary

How:

  1. Complete your starting-up steps.
  2. Cover the chest of drawers with a towel or paper towels and place your assembled supplies on it. Do not place the urinal on the overbed table.
  3. The client should be lying in bed, on their back with the bed flat. Fanfold the bed linens to the client’s knees. The client may want to sit on the side of the bed or stand; assist as needed following the client’s care plan or ISP.
  4. Don gloves.
  5. If the client is wearing a hospital gown, pull it up slightly to expose the perineum. If the client is wearing pajama bottoms, lower them to their knees.
  6. If the bed protector under the client is soiled, remove and replace it with a clean one. Place the soiled bed protector in the linen bag. If there is no bed protector under the ­client, place one under them to protect the bed linens from becoming soiled.
  7. Line the opening of the urinal with the washcloth if it is uncomfortable for the client or if they have fragile skin.
  8. Ask the client to position the urinal. If they are unable, place their penis inside of the urinal between their thighs. Adjust the bed linens as necessary to cover the client.
  9. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  10. Raise the head of the bed to a semi-Fowler’s position.
  11. Provide privacy for the client. Hand them the call light and ask them to use it when done using the urinal.
  12. Once the client has finished with the urinal, don gloves, pull back the linens, and remove the urinal with your dominant hand, being careful not to spill the contents. If the urinal was lined with a washcloth, remove it with your nondominant hand and place it in the linen bag. With your nondominant hand, adjust the bed linens as necessary to cover the client.
  13. Empty the contents of the urinal into the toilet and rinse it. Measure the urine output if the client is on intake and output, as indicated on the care plan.
  14. Empty the rinse water into the toilet and rinse. Repeat as necessary until the urinal is clean. Dry the urinal with paper towels and discard them into the wastebasket. Place the urinal in the designated storage area in the client’s room.
  15. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  16. Complete your finishing-up steps.

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Measuring Urine Output From a Urinal

When: ​Each time a client uses the urinal if a client is on intake and output.

Why: ​To help assess the client’s fluid balance.

What: ​Supplies needed for this skill include:

  • Gloves
  • Urinal
  • Bed protector
  • Washcloth, as necessary

How:

  1. Complete your starting-up steps.
  2. Once the client has finished with the urinal, don gloves, pull back the linens and remove the urinal with your dominant hand, being careful not to spill the contents. If the urinal was lined with a washcloth, remove it with your non-dominant hand and place it in the linen bag. With your non-dominant hand, adjust the bed linens as necessary to cover the client.
  3. Place clean paper towels on the bathroom countertop. Place the graduate on top of the paper towels.
  4. Bend at the knees to measure the urine in the graduate at eye level. Measure the amount of urine to the closest 25 mL hash line. Make a note of the amount for later documentation.
  5. Empty the contents of the urinal into the toilet and rinse it. Empty the rinse water into the toilet. Repeat as necessary until the urinal is clean. Dry the urinal with paper towels and discard them into the wastebasket. Place the urinal in the designated storage area in the client’s room.
  6. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
  7. Complete your finishing-up steps.

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Assisting the Client to the Commode or Toilet

When: Assist the client to the commode or toilet every two hours or as requested by the client.

Why: To empty the bowel and/or bladder.

What: Supplies needed for this skill include

  • Toilet paper
  • Adult wipes

How:

  1. Complete your starting-up steps.
  2. Verify the client’s level of assistance as listed on the care plan.
  3. Position the wheelchair perpendicular to the toilet so the client can grasp the grab bars next to the toilet. Lock the brakes on the wheelchair.
  4. Ensure the client has shoes or non-skid slipper socks on their feet.
  5. Apply a gait belt if indicated on the care plan. Ask the client to assist you during the transfer by grasping the grab bars or pushing their body upward off the arms of the wheelchair to a standing position on the count of three.
  6. Stand on the side of the client. Ensure that their feet are flat on the floor. Assume a wide base of support, bending at the knees.
  7. Grasp the gait belt if used. On the count of three, assist the client to a standing position.
  8. Instruct the client to pivot until the edge of the toilet seat is behind their legs. Lower pants and undergarments.
  9. On the count of three, lower their body to a seated position onto the toilet.
  10. Ensure that the client’s hips and buttocks are towards the back of the toilet seat and that they are properly aligned.
  11. Allow the client time to use the toilet.
  12. Once complete assist the client with cleaning the peri area as needed. Complete hand hygiene as needed.
  13. Ask the client to grasp the grab bars and on the count of three to stand. Reposition undergarments and pants.
  14. Instruct the client to pivot until the edge of the wheelchair is behind their legs.
  15. Ask the client, on the count of three, to lower their body to a seated position into the wheelchair.
  16. Ensure that the client’s hips and buttocks are towards the back of the wheelchair and that they are properly aligned.
  17. Complete your finishing-up steps.

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Administering a Suppository

When: A suppository is administered typically if a client has not had a bowel movement for 3 days, or when ordered by the physician.

Why: ​A suppository is given to alleviate constipation.

What: ​Supplies needed for this skill include:

  • Bed protector
  • Lubricant
  • Gloves
  • A bed pan
  • Commode or toilet depending on the client’s mobility
  • Washcloths and towels or toilet tissue as needed

How:

  1. Complete your starting-up steps.
  2. Place the client in a left side lying position with a bed protector under the client’s buttocks.
  3. Don gloves.
  4. Expose the buttocks and locate the anus.
  5. Ask the client to take a few breaths and then tell the client when you will be inserting the tube. Insert the rectal suppository into the anus about 3 to 4 inches.
  6. Ask the client to retain the suppository in the rectum for approximately 30 minutes for it to work.
  7. Assist the client with using the bed pan, commode or toilet.
  8. Assist the client with peri care as needed after the bowel movement.
  9. Complete your finishing-up steps.

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Administering Enema With Tap Water and Soap Suds

When: ​An enema is administered typically if a client has not had a bowel movement for 5 days, or when ordered by the physician.

Why: ​An enema is given to alleviate constipation.

What: ​Supplies needed for this skill include:

  • Gloves
  • Enema bag
  • Tubing with rectal tube
  • Clamp
  • Tap water
  • Lubricant
  • Castile soap
  • Bed protector
  • A bed pan
  • Commode or toilet depending on the client’s mobility
  • Washcloths and towels or toilet tissue as needed

How:

  1. Complete your starting-up steps.
  2. Place the client in a left side lying or Sim’s position if tolerated with a bed protector under the client’s buttocks.
  3. Fill the enema bag with warm tap water and include the provided castile soap. Hang the bag on an IV pole and prime the tubing to remove any air.
  4. Have your supplies within reach including cleaning supplies and the bed pan or commode, and shoes if the client will be using the toilet or commode.
  5. Don gloves.
  6. Lubricate the tip of the tubing 3 to 4 inches.
  7. Ask the client to take a few breaths and then tell the client when you will be inserting the tube.
  8. Expose the buttocks and locate the anus. Insert the tube into the anus about 3 to 4 inches. Hold the tubing in place.
  9. Unclamp the tubing to allow the water to enter the rectum. The higher the bag is placed above the client the faster the water will enter. Start low and slowly raise if needed.
  10. Remove the tubing and ask the client to hold the solution in the rectum for about 5 to 15 minutes as tolerated.
  11. Assist the client with using the bed pan, commode or toilet.
  12. Assist the client with peri care as needed after the bowel movement.
  13. 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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