CNA Comprehensive Clinical Skills and Procedures Guide: 23 Essential Nursing Skills and Essential Procedures

Overview of Clinical Skills Listing

Organization: The 23 clinical skills provided in this guide are arranged in alphabetical order, with one notable exception: Hand Hygiene (Hand Washing).
Hand Hygiene Priority: Hand Hygiene is listed as Skill 1 to serve as a constant reminder of the critical importance of performing this action before beginning all other clinical skills.
Clinical Steps: Each skill is followed by numbered lines detailing the specific steps required for successful performance.
Critical Element Steps: Any step formatted in bold type within the original documentation is designated as a Critical Element Step, indicating it is essential for safety and competency.

Skill 1: Hand Hygiene (Hand Washing)

Initial Engagement: Address the client by name and introduce yourself to the client by name.
Water Management: Turn on the water at the sink.
Wetting: Thoroughly wet the hands and the wrists.
Soap Application: Apply soap to the hands.
Lathering and Friction: Lathers all surfaces of the wrists, hands, and fingers. This process must produce friction and last for at least $20$ , (twenty) seconds. During this time, hands must be kept lower than the elbows and fingertips must be pointed down.
Nail Cleaning: Clean the fingernails by rubbing the fingertips against the palms of the opposite hand.
Rinsing: Rinse all surfaces of the wrists, hands, and fingers. Continue to keep the hands lower than the elbows with fingertips pointed down.
Drying: Use clean, dry paper towels to dry all surfaces of the fingers, hands, and wrists. Drying should start at the fingertips. Dispose of the used paper towels in a waste container.
Faucet Closure: Use a clean, dry paper towel to turn off the faucet and dispose of it in a waste container, or use a knee/foot control if available.
Safety: Do not touch the inside of the sink at any time during the procedure.

Skill 2: Applies One Knee-High Elastic Stocking (TED Hose)

Communication: Explain the procedure to the client, speaking clearly, slowly, and directly while maintaining face-to-face contact whenever possible.
Privacy: Provide privacy using a curtain, screen, or door.
Positioning: Ensure the client is in a supine position (lying down in bed) while the stocking is applied.
Stocking Preparation: Turn the stocking inside-out, reaching at least to the heel.
Initial Placement: Place the foot of the stocking over the client's toes, foot, and heel.
Application: Pull the top of the stocking over the foot, heel, and leg.
Gentle Movement: Move the foot and leg gently and naturally. Avoid using force or over-extending the limb and joints.
Verification of Correct Fit: The procedure is finished with no twists or wrinkles. The heel of the stocking (if present) must be positioned over the client's heel. The opening in the toe area (if present) should be either over or under the toe area. (Note: If using a mannequin, the candidate may state the stocking needs to be wrinkle-free).
Safety and Termination: Place the signaling device within reach and ensure the bed is in the low position. Wash hands after completing the skill.

Skill 3: Assists to Ambulate Using a Transfer Belt (Gait Belt)

Information and Privacy: Explain the procedure to the client with face-to-face contact. Provide privacy.
Pre-Standing Preparation:
- Ensure the client is wearing non-skid shoes or footwear.
- Ensure the bed is at a safe level.
- Check and/or lock the bed wheels.
- Assist the client to a sitting position with feet flat on the floor.
- Apply the transfer belt (gait belt) securely at the waist over the clothing or gown.
Instructions: Provide instructions so the client can assist in standing. This includes a prearranged signal to alert the client when to begin standing.
The Stand: Stand facing the client. Position yourself to ensure safety for both yourself and the client. Count to three (or use the prearranged signal).
Upward Grasp: On the signal, gradually assist the client to stand by grasping the transfer belt on both sides with an upward grasp. Maintain stability of the client's legs by standing knee-to-knee or toe-to-toe.
Ambulation: Walk slightly behind and to one side of the client for a distance of ten ( $10$ ) feet while holding onto the belt.
Return to Bed: Assist the client back to bed and remove the transfer belt.
Post-Procedure: Place the signaling device within reach and ensure the bed is in the low position. Wash hands.

Skill 4: Assists with Use of Bedpan

Communication and Privacy: Explain the procedure directly and provide privacy.
Initial Setup: Lower the head of the bed before placing the bedpan. Put on clean gloves.
Placement: Position the bedpan correctly under the client's buttocks.
Hygiene Transition: Remove and dispose of gloves without self-contamination. Wash hands.
Positioning for Use: Raise the head of the bed. Ensure toilet tissue and hand wipes are within reach. Instruct the client to clean their hands with the wipe when finished.
Signaling: Place the signaling device within reach and ask the client to signal when they are finished.
Removal of Bedpan:
- Put on clean gloves.
- Lower the head of the bed before removal.
- Ensure the client is covered except during the actual placement and removal.
Cleaning and Disposal: Empty and rinse the bedpan. Pour the rinse into the toilet. Place the bedpan in the designated dirty supply area.
Skill Completion: Remove gloves, wash hands, and ensure the signaling device is within reach with the bed in the low position.

Skill 5: Cleans Upper or Lower Denture

Initial Protection: Put on clean gloves.
Sink Preparation: Line the bottom of the sink (e.g., with a washcloth table barrier) and/or partially fill the sink with water before holding the denture over it.
Preliminary Rinse: Rinse the denture in moderate temperature running water before brushing.
Brushing: Apply denture toothpaste to a toothbrush and brush all surfaces of the denture.
Final Rinse: Rinse all surfaces of the denture under moderate temperature running water.
Equipment Care: Rinse the denture cup and lid. Place the denture in the cup with moderate temperature water or solution and secure the lid.
Storage: Rinse the toothbrush and place it in the designated toothbrush basin or container.
Technique: Maintain clean technique throughout the placement of the toothbrush and denture.
Cleanup: Remove and dispose of the sink liner appropriately and/or drain the sink. Remove gloves and wash hands.

Skill 6: Counts and Records Radial Pulse

Engage Client: Explain the procedure, maintaining face-to-face contact.
Locating Pulse: Place fingertips on the thumb side of the client's wrist to locate the radial pulse.
Counting: Count the beats for one ( $1$ ) full minute.
Recording Requirements: Place the signaling device within reach. Wash hands before recording the data.
Accuracy Standard: Records the pulse rate within plus or minus ( $±$ ) $4$ beats of the evaluator's reading.

Skill 7: Counts and Records Respirations

Procedure: Explain the procedure for testing purposes. Count respirations for one ( $1$ ) full minute.
Data Entry: Place the signaling device within reach and wash hands before recording.
Accuracy Standard: Records the respiration rate within plus or minus ( $±$ ) $2$ breaths of the evaluator's reading.

Skill 8: Donning and Removing PPE (Gown and Gloves)

Donning Gown: Pick up the gown and unfold it. Facing the back opening, place arms through sleeves. Fasten the neck opening. Secure the waist, ensuring the back of the clothing is covered as much as possible.
Donning Gloves: Put on gloves, ensuring the cuffs of the gloves overlap the cuffs of the gown.
Removing First Glove: Before removing the gown, use one gloved hand to grasp the other glove at the palm and remove it.
Removing Second Glove: Slip the fingers of the ungloved hand underneath the cuff of the remaining glove at the wrist. Remove it by turning it inside out.
Disposal: Dispose of gloves into the designated waste container without self-contamination.
Removing Gown: Unfasten the gown at the waist and neck. Remove the gown without touching the outside. Hold it away from the body, avoiding the floor. Turn the gown inward so it remains inside out.
Final Steps: Dispose of the gown in the designated container and wash hands.

Skill 9: Dresses Client with Affected (Weak) Right Arm

Engagement: Explain the procedure and provide privacy.
Choice: Ask the client which shirt they would like to wear and ensure the chest is covered during the process.
Undressing: Remove the gown from the left (unaffected) side first, then the right (affected/weak) side. Dispose of the gown in the soiled linen container.
Dressing: Assist the client in putting the right (affected/weak) arm through the right sleeve of the shirt before placing the garment on the left (unaffected) arm.
Physical Handling: Move the body gently, avoiding over-extension of joints. Finish with clothing in place.
Completion: Place the signaling device within reach, low bed position, and wash hands.

Skill 10: Feeds Client Who Cannot Feed Self

Identity Verification: Explain the procedure. Before feeding, look at the name card on the tray and ask the client to state their name.
Positioning: The client must be in an upright sitting position between $75-90$ degrees.
Preparation: Place the tray where the client can see the food. Clean the client's hands before beginning. Sit in a chair facing the client.
Feeding Process: Describe the food and beverages on the tray. Ask the client what they prefer to eat first. Use a spoon to offer one bite of each type of food, stating the content of each spoonful. Offer a beverage at least once during the meal. Ask the client if they are ready for the next bite or sip.
Conclusion: Clean the client's mouth and hands. Remove the food tray. Leave the client in the upright position ( $75-90$ degrees) with the signaling device within reach. Wash hands.

Skill 11: Gives Modified Bed Bath (Face and One Arm, Hand, and Underarm)

Initial Setup: Explain the procedure and provide privacy. Remove the gown for disposal in soiled linen, ensuring the chest and lower body remain covered.
Water Safety: Check water temperature and have the client verify comfort.
Preparation: Put on clean gloves.
Face Cleaning: Wash the eyes with a wet washcloth (no soap). Use a different area of the washcloth for each stroke, moving from the inner aspect to the outer aspect. Continue to wash the face and dry with a cloth towel.
Upper Body Cleaning: Expose one arm and place a towel underneath. Apply soap to a wet washcloth. Wash fingers, nails, hand, arm, and underarm. Maintain coverage for the rest of the body.
Finishing Upper Body: Rinse and dry the limb. Move joints gently.
Dressing and Maintenance: Put a clean gown on the client. Empty, rinse, and dry the basin; place it in the dirty supply area. Dispose of linen properly, avoiding contact with your own clothing.
Final Steps: Remove gloves, wash hands, ensure signaling device is reach, and bed is low.

Skill 13: Measures and Records Urinary Output

Handling: Put on clean gloves before handling the bedpan. Pour contents into the measuring container (graduate cylinder) without spilling.
Rinsing: Rinse the bedpan into the toilet.
Measurement: Measure at eye level with the container on a flat surface. If the measurement falls between lines, round up to the nearest $25\,ml/cc$ .
Disposal: Empty the contents and the rinse into the toilet.
Recording: Remove gloves and wash hands before recording.
Accuracy Standard: Records output within plus or minus ( $±$ ) $25\,ml/cc$ of the evaluator’s reading.

Skill 14: Measures and Records Weight of Ambulatory Client

Safety: Ensure non-skid footwear is on the client before they walk to the scale.
Calibration: Set the scale to zero before the client steps on.
Process: Have the client step on the center of the scale. Obtain weight and have the client step off.
Recording: Wash hands before recording.
Accuracy Standard:
- In pounds: Within plus or minus ( $±$ ) $2\,lbs$ of evaluator.
- In kilograms: Within plus or minus ( $±$ ) $0.9\,kg$ of evaluator.

Skill 15: Modified Passive Range of Motion (PROM) for One Knee and One Ankle

Communication: Explain procedure and provide privacy. Instruct the client to report any pain.
Positioning: Ensure the client is supine.
Knee Exercises (Flexion/Extension): Support the leg at the knee and ankle. Bend the knee and return to normal position. Repeat at least three ( $3$ ) times unless pain is verbalized. Move joints gently and slowly.
Ankle Exercises (Dorsiflexion/Plantar Flexion): Support the foot and ankle. Push/pull the foot toward the head (dorsiflexion) then push/pull the foot down/toes down (plantar flexion). Repeat at least three ( $3$ ) times. Move joints gently and slowly.
Closing: Place signaling device, ensure low bed, and wash hands.

Skill 16: Modified Passive Range of Motion (PROM) for One Shoulder

Instructions: Explain the procedure, provide privacy, and instruct the client to report pain.
Shoulder Flexion/Extension: Support the arm at the elbow and wrist. Raise the straightened arm from the side upward to ear level and return to the side. Perform at least three ( $3$ ) times.
Shoulder Abduction/Adduction: Support at the elbow and wrist. Move the straightened arm away from the side to shoulder level and return to the side. Perform at least three ( $3$ ) times.
Safety: Move joints slowly and smoothly; stop if the client verbalizes pain. Finish by washing hands.

Skill 17: Positions on Side

Preparation: Explain procedure, provide privacy, and lower the head of the bed.
Safety Measure: Raise the side rail on the side to which the body will be turned.
Turning: Assist the client to roll toward the raised side rail.
Support Points:
1. Head: Place or adjust a pillow.
2. Arm/Shoulder: Reposition so the client is not lying on their arm.
3. Upper Arm: Support with a device.
4. Back: Place a supportive device behind the back.
5. Legs: Place a supportive device between the legs with the top knee flexed; ensure both knee and ankle are supported.
Conclusion: Signaling device in reach, bed low, wash hands.

Skill 18: Provides Catheter Care for Female

Setup: Explain procedure, check water temperature for comfort, and put on clean gloves.
Protection: Place a linen protector under the perineal area and buttocks.
Exposure: Expose the catheter area only between the hip and knee.
Cleaning Technique: Apply soap to a wet washcloth. Hold the catheter at the meatus without tugging. Clean at least four ( $4$ ) inches of the catheter moving in only one direction (away from the meatus). Use a clean area of the washcloth for every stroke.
Rinsing: Rinse at least four ( $4$ ) inches moving away from the meatus with a clean area of the cloth for each stroke.
Drying: Dry at least four ( $4$ ) inches moving away from the meatus.
Cleanup: Empty/rinse/dry the basin. Dispose of linen and protector appropriately. Remove gloves and wash hands.

Skill 19: Provides Foot Care on One Foot

Preparation: Explain procedure, check water temperature, and place the basin on a protective barrier.
Washing: Put on gloves and place the bare foot into the water. Apply soap to a wet washcloth and wash the foot, including between the toes.
Rinsing and Drying: Rinse and thoroughly dry the foot, especially between the toes.
Lotion Application: Apply lotion to the top and bottom of the foot, but exclude the area between the toes. Remove excess lotion with a towel.
Maintenance: Support the foot and ankle throughout the procedure. Clean the basin and dispose of linen. Wash hands.

Skill 20: Provides Mouth Care

Preparation: Explain procedure and provide privacy. Position the client upright at $75-90$ degrees.
Initial Setup: Put on gloves and place a towel across the client's chest.
Toothbrush Prep: Moisten the toothbrush with water and apply toothpaste.
Brushing: Clean the mouth, including the tongue and all tooth surfaces, using gentle motions. Maintain clean technique for the toothbrush.
Rinsing: Hold an emesis basin to the client's chin while they rinse.
Conclusion: Wipe the client's mouth and remove the protector. Clean equipment, dispose of linen, remove gloves, and wash hands.

Skill 21: Provides Perineal Care (Peri-Care) for Female

Setup: Explain procedure, check water temperature, put on gloves, and place a linen protector under the buttocks.
Exposure: Expose only the area between hips and knees.
Genital Cleaning: Apply soap to a wet washcloth. Wash moving from front to back, using a clean area of the cloth for each stroke. Rinse and dry using the same front-to-back motion and clean cloth areas.
Rectal Cleaning: Turn the client to their side. Wash the rectal area moving from front to back with clean cloth areas. Rinse and dry moving front to back.
Cleanup: Reposition the client. Clean the basin and dispose of linen and the protector. Remove gloves and wash hands.

Skill 22: Transfers from Bed to Wheelchair Using Transfer Belt

Positioning Wheelchair: Position the wheelchair alongside the bed (head of bed facing foot or vice-versa). Lock the wheelchair wheels and fold up or remove footrests.
Client Prep: Ensure the bed is at a safe level and wheels are locked. Assist the client to a sitting position with feet flat on the floor. Ensure shoes are on.
Belt Application: Secure the transfer belt over the clothing/gown. Provide standing instructions and a signal.
The Transfer: Stand facing the client. On the signal (count of three), assist the client to stand with an upward grasp on both sides of the belt. Maintain stability knee-to-knee or toe-to-toe.
Seating: Assist the client to turn and stand in front of the wheelchair (back of legs against the chair). Lower the client into the chair with hips touching the back. Remove the belt and position feet on footrests.

Skill 23: Measures and Records Manual Blood Pressure

State Specific Note: This must not be substituted for electronic BP (Skill 12).
Asepsis: Wipe the stethoscope bell/diaphragm and earpieces with alcohol before use.
Application: Position the arm palm-up and expose the upper arm. Feel for the brachial artery. Place the cuff snugly with the sensor over the artery.
Inflation: Inflate the cuff to between $160\,mmHg$ to $180\,mmHg$ . If a beat is heard immediately upon deflation, re-inflate to no more than $200\,mmHg$ .
Measurement: Deflate slowly and note the first sound (systolic) and last sound (diastolic). If rounding is needed, round UP to the nearest $2\,mm$ of mercury.
Recording: Wash hands before recording.
Accuracy Standard: Records both pressures within plus or minus ( $±$ ) $8\,mmHg$ of the evaluator’s reading.