A Certified Nursing Assistant (CNA) is a frontline healthcare provider who assists patients with activities of daily living and provides routine nursing care under the supervision of a licensed nurse. To ensure competence, candidates must pass a state-administered certification exam, which includes a practical skills test. This test evaluates mastery of a standardized set of procedures, often summarized as the “22 skills,” representing the core hands-on duties required of the job in hospitals and long-term care settings.
Foundational Care and Hygiene Skills
These skills focus on maintaining patient comfort, cleanliness, and dignity while preventing infection. Proper technique is paramount for tasks like oral hygiene, which involves thoroughly cleaning a resident’s natural teeth or dentures. For unconscious patients, oral care requires using specialized sponge swabs and positioning the patient on their side to prevent aspiration.
A partial bed bath involves washing the face, hands, underarms, back, and perineal area of a patient who cannot bathe themselves. Modesty is maintained by only exposing one body part at a time. Perineal care, the cleaning of the genital and anal areas, is a distinct procedure requiring meticulous, front-to-back strokes to reduce the risk of urinary tract infections (UTIs).
Assisting a resident with a bedpan requires attention to privacy and proper body alignment. The CNA must ensure the bedpan is correctly positioned and removed without spillage, then clean the patient and dispose of the waste appropriately. Bed making, specifically changing linens while the patient remains in the bed (occupied bed), ensures a clean environment. This requires the CNA to turn the patient safely to one side to complete the process.
Feeding assistance is required for patients who cannot feed themselves, demanding an upright position to prevent aspiration. The CNA must check the food temperature, offer fluids, and maintain a slow, respectful pace while communicating clearly. Dressing a resident, especially one with a weak side, requires a specific sequence: dressing the weak side first and undressing the weak side last to minimize strain.
Safety, Mobility, and Assistance Skills
Safe patient movement protects the patient from falls and pressure injuries, and the CNA from musculoskeletal injury. Proper body mechanics dictate that the CNA should bend at the knees, keep the back straight, and lift with the leg muscles, holding the patient close to the body. Locking the wheels on beds and wheelchairs before any transfer is a mandatory safety step that prevents sudden movement.
Transferring a resident from a bed to a wheelchair frequently involves using a gait belt, applied snugly around the patient’s waist to provide a secure handhold. The CNA assists the patient to stand on a count, pivots toward the chair, and gently lowers them, ensuring their feet are placed correctly. When assisting a resident to ambulate, the gait belt is held firmly, and the CNA walks slightly behind and to the side to offer immediate support if they become unsteady.
Repositioning a resident in bed, such as turning them onto their side, must be done at least every two hours to prevent pressure ulcers (bedsores) and promote circulation. This requires careful use of pillows to support the head, back, and limbs to maintain proper body alignment. Passive Range of Motion (ROM) exercises involve the CNA gently moving a patient’s joints through their natural motions, like flexion, extension, and rotation, to prevent contractures and joint stiffness.
These exercises must be executed slowly and smoothly, stopping immediately if the patient reports pain. Applying anti-embolic stockings (TED hose) is a skill focused on circulation, preventing deep vein thrombosis (DVT) by providing graduated compression to the legs. The stocking must be applied smoothly, without wrinkles, to ensure even pressure and avoid restricting blood flow.
Clinical Measurement and Reporting Skills
Accurate data collection forms the basis of patient monitoring. Measuring vital signs—pulse, respiration, and blood pressure—provides objective data on a resident’s physiological status. The radial pulse is typically counted for one full minute to ensure accuracy, noting the rate, rhythm, and strength.
Respiration rate is counted for one minute without the patient’s awareness, often immediately after taking the pulse, to prevent them from consciously altering their breathing. Any readings outside the normal adult range (12 to 20 breaths per minute) must be promptly reported to the nurse. Measuring blood pressure involves using a sphygmomanometer and stethoscope to identify the systolic and diastolic pressures.
Measuring and recording a resident’s weight monitors nutritional status, fluid balance, and medication effectiveness. The CNA must ensure the scale is zeroed, the resident is wearing non-skid footwear, and the recorded weight is precise. Measuring input and output (I&O) is also critical for monitoring fluid balance, especially in residents with heart or kidney conditions.
I&O involves accurately measuring all fluids a resident consumes (intake) and all fluids they excrete, such as urine output. Collecting a non-sterile urine specimen requires wearing gloves and ensuring the container is correctly labeled and transported to the laboratory without contamination. All measurements and observations, including abnormal findings, must be recorded precisely and communicated to the supervising nurse immediately.
The CNA Skills Examination Process
The practical skills test is a component of CNA certification designed to assess hands-on competence in a controlled, simulated environment. Candidates perform procedures on either a mannequin or a live actor playing the resident role. The examination does not require demonstration of all 22 potential skills; candidates are usually asked to perform five tasks selected at random from the full pool of procedures.
Proper hand hygiene is always included and is often the first skill performed, serving as a foundational demonstration of infection control. An evaluator, typically a Registered Nurse (RN), observes the performance and scores the candidate based on a detailed checklist. The entire process is timed, with candidates usually allotted between 25 and 35 minutes to complete all assigned tasks.
A defining feature of the skills test is the concept of “critical steps,” which are mandatory actions that must be performed correctly for the skill to pass. Missing a critical step results in an automatic failure for that skill. Common critical steps include:
- Identifying the patient.
- Locking the bed or wheelchair brakes before a transfer.
- Placing the call light within reach.
- Maintaining proper infection control through handwashing.
Candidates must also demonstrate “Indirect Care,” which involves communicating clearly with the resident, explaining the procedure, and ensuring their comfort and safety. After completing the final task, the candidate must perform the closing procedure. This includes ensuring the patient is safe and comfortable, the bed is in the lowest position, and the call light is accessible, before performing final hand hygiene.