Skill 9-1

Assisting a Patient With Repositioning in Bed

Skill Variation: Using a Full-Body Sling to Reposition a Patient

Patients experiencing decreased mobility as a result of illness or injury may be unable to reposition themselves. The patient is at risk for injuries from friction and shearing forces while being moved. Knowledge of correct body alignment, SPHM, and assistive devices to turn the patient in bed are crucial to achieve patient movement and avoid injury. Use a decision-making tool to help make decisions about SPHM. One suggested decision-making strategy is outlined in Fundamentals Review 9-4. This tool includes suggestions for associated SPHM equipment. Another example of a decision-making tool is provided in Figure 1. If the patient is fully able to assist in turning, allow the patient to complete the movement independently, with safe supervision. If the patient is partially able or unable to assist, friction-reducing devices, lifting/repositioning sheets, lateral transfer devices, and a full-body sling are potential equipment to consider, based on screening and assessment. Consider available bed features (turning, pressure release, rotation) to assist with the action (VA Mobile Health, n.d.).

Fundamentals Review 9-3 reviews examples of equipment and assistive devices that are available to aid in patient movement and handling. Refer to Box 9-1 (on page 548) for additional considerations related to mobility and safe handling of people with dementia. The procedure below describes general guidelines for repositioning a patient; the Skill Variation at the end of the skill discusses using a full-body sling to reposition the patient. Refer to facility policy and procedures and specific manufacturer guidelines related to other available devices and equipment.

Delegation Considerations

Assisting a patient to turn in bed may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Friction-reducing sheet or lifting/repositioning sheet or other device (based on assessment)
Lateral transfer device or full-body sling lift and cover sheet (based on assessment)
Bed surface that inflates to aid in turning
Pillows or other supports to help the patient maintain the desired position after turning and to maintain correct body alignment for the patient
Additional caregivers and/or safe handling equipment to assist, based on assessment
Nonsterile gloves, if indicated; other PPE as indicated

Assessment

Assess the situation to determine the need to reposition the patient. Check the health care record for any conditions or prescribed interventions that may influence the patient's ability to move or to be repositioned. Perform a pain assessment before the time for the activity. If the patient reports pain, administer the prescribed medication in sufficient time to allow for the full effect of the analgesic. Assess for tubes, IV lines, incisions, or equipment that may alter the positioning procedure. Use available algorithms to aid in assessment and decision making. Assess the patient's level of consciousness, ability to understand and follow directions, and ability to assist with moving. Use available decision-making tools or algorithms to aid in assessment and decision making. Assess the patient's ability to assist with moving and the need for assistive devices. Determine the need for bariatric equipment. Assess the patient's skin for signs of irritation, redness, edema, or blanching.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Activity intolerance
Deconditioning
Injury risk

Outcome Identification and Planning

The expected outcome to achieve when repositioning a patient in bed is that the patient is repositioned without injury to patient or nurse. Additional outcomes may include the following: the patient reports improved comfort, and the patient maintains proper body alignment.

Implementation

Action	Rationale
1. Review the health record for prescribed interventions and plan of care for patient activity. Identify any movement limitations, conditions that may influence the patient's ability to move or be positioned, and the ability of the patient to assist with turning. Consult a patient handling algorithm or other decision-making tool to plan an appropriate approach to moving the patient.	Checking the health care record validates the correct patient and correct procedure. Identification of limitations and ability along with use of an algorithm helps to prevent injury and aids in determining the best plan for patient movement.
2. Gather any positioning aids or supports, if necessary.	Having aids readily available promotes efficient time management.
3. Perform hand hygiene. Put on PPE, as indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient. Explain the procedure to the patient.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
5. Close the curtains around the bed and close the door to the room, if possible. Position at least one nurse on either side of the bed. Place pillows, wedges, or any other support to be used for positioning within easy reach. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016). Lower both side rails.	Closing the door or curtains provides for privacy. Proper bed height helps reduce back strain while performing the procedure. Proper positioning and lowering of the side rails facilitate moving the patient and minimizes strain on the nurses.
6. If not already in place, position a friction-reducing sheet or lifting/repositioning sheet or other transfer device under the patient, based on assessment.	Friction-reducing/lifting/repositioning sheets and other transfer devices aid in preventing shearing and in reducing friction and the force required to move the patient.
7. Remove all pillows from under the patient's head, back, or legs. If moving the patient up in the bed, leave one pillow at the head of the bed, leaning upright against the headboard.	Removing pillows from under the patient facilitates movement; placing a pillow at the head of the bed prevents accidental head injury against the top of the bed.
8. Based on the screening and assessment information, position at least one nurse or other health care provider on either side of the bed, and lower both side rails.	Proper positioning and lowering the side rails facilitate moving the patient and minimize strain on the care providers.
9. If the patient is fully able to assist in repositioning, allow the patient to complete the move independently, with supervision.	Safe supervision allows for intervention by care giver if necessary and reduces the risk for injury.
10. If the patient is partially able or unable to assist, make use of friction-reducing devices, lifting/repositioning sheets (Figure 2), lateral transfer devices, full-body sling lift and/or engage the turning or rotation to assist with the action (VA Mobile Health, n.d.).	Use of SPHM equipment is necessary to reduce risk of injury to patient and care providers (Fragala et al., 2016; OSHA and Joint Commission Resources Alliance, 2017; VA Mobile Health, n.d.).
11. If turning, activate the bed-turn mechanism to inflate the side of the bed behind the patient's back.	Activating the turn mechanism inflates the side of the bed for approximately 10 seconds, aiding in propelling the patient to turn, and reducing the work required by the nurse. This helps avoid injury to the nurse or other care provider.
12. Alternatively, follow manufacturer's directions to utilize the ceiling lift or full-body lifting device with the repositioning or supine sling or air-assisted transfer device. Refer to the Skill Variation at the end of the skill for guidelines related to use of a full-body sling lift.	Use of SPHM equipment is necessary to reduce risk of injury to patient and care providers (Fragala et al., 2016; OSHA and Joint Commission Resources Alliance, 2017; VA Mobile Health, n.d.).
13. Once the patient has been repositioned, make the patient comfortable and position in proper alignment, using pillows or other supports behind the patient's back (pull the shoulder blade forward and out from under the patient), under the leg and arm, as needed. Readjust the pillow under the patient's head. Elevate the head of the bed as needed for comfort.	Positioning in proper alignment with supports ensures that the patient will be able to maintain the desired position and will be comfortable. Positioning the shoulder blade removes pressure from the bony prominence.
14. Place the bed in the lowest position, with the side rails up, as indicated. Make sure the call bell and other necessary items are within easy reach.	Adjusting the bed height ensures patient safety. Having the call bell and essential items readily available helps promote safety.
15. Clean transfer aids, per facility policy, if not indicated for single-patient use. Remove gloves and other PPE, if used. Perform hand hygiene.	Proper cleaning of equipment between patient use prevents the spread of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been achieved when the patient has been repositioned without injury to patient or nurse, the patient has reported improved comfort, and the patient has maintained proper body alignment.

Documentation

Guidelines

Many facilities provide areas on the bedside flow sheet to document repositioning. Be sure to document the time the patient's position was changed, use of supports, and any pertinent observations, including skin assessment. Document the patient's tolerance of the position change. Document completed assessment algorithm for patient handling and movement decision and SPHM aids used to facilitate movement.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You are attempting to move a patient up in the bed when you realize your initial assessment was inaccurate and the patient is not able to participate with repositioning to the extent you thought: Cover the patient, make sure all rails are up, lower the bed to the lowest position, and take a moment to reassess the situation using SPHM decision-making tool. Obtain the necessary equipment and number of personnel as indicated. Document the assessment and necessary equipment in the plan of care for continuity of care.

Special Considerations

Institute Bariatric Algorithms for any patient who weighs more than 300 lb, or is 100 lb over ideal weight, or who has a body mass index (BMI) over 40 (VHA CEOSH, 2015).
When moving a patient with a leg or foot problem, such as a cast, wound, or fracture , one caregiver should be assigned to monitor movement of that extremity to reduce risk of further injury.

Using a Full-Body Sling to Reposition a Patient

Review the health care record for prescribed interventions and plan of care for patient activity. Identify any movement limitations, conditions that may influence the patient's ability to move or be positioned, and the ability of the patient to assist with repositioning.Consult the patient handling algorithm to plan an appropriate approach to moving the patient(see Figure 1 in Skill 9-1).
Gather any positioning aids or supports, if necessary.
Perform hand hygiene and put on gloves and/or other PPE, as indicated.
Identify the patient. Explain the procedure to the patient.
Close the curtains around the bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height. Adjust the head of the bed to a flat position or as low as the patient can tolerate.
Remove all pillows from under the patient. If moving the patient up in the bed, leave one at the head of the bed, leaning upright against the headboard.
Position at least one nurse on either side of the bed, and lower both side rails.
Place the cover sheet on the sling surface. Place the sling under the patient.
Roll the base of the lift under the side of the bed nearest to the chair.Center the frame over the patient. Lock the wheels of the lift.
Using the base-adjustment lever, widen the stance of the base of the device.
Position yourself and the other caregiver at the patient's midsection. If necessary, additional staff can support the patient's legs.
Crank or engage the mechanism to raise the sling, with the patient, up off the bed. Raise the patient just high enough to clear the bed surface.
Guide the sling and relocate the patient to the appropriate place at the head of the bed.
Release the sling slowly or activate the lowering device on the lift and slowly lower the patient to the bed surface.
Remove the sling or leave in place for future use, based on facility policy.
Assist the patient to a comfortable position and readjust the pillows and supports, as needed.
Raise the side rails. Place the bed in the lowest position. Make sure the call bell and other necessary items are within easy reach.
Clean transfer aids, per facility policy, if not indicated for single-patient use. Remove gloves and any other PPE, if used, and perform hand hygiene.

EVIDENCE FOR PRACTICE

Safe Patient Handling and Mobility

VA Mobile Health. (n.d.). Safe patient handling. (Version 1.3.3). [Mobile app]. U. S. Department of Veteran Affairs. https://mobile.va.gov/app/safe-patient-handling

VHA Center for Engineering & Occupational Safety and Health (CEOSH). (2015). Bariatric safe patient handling and mobility guidebook: A resource guide for care of persons of size. https://www.asphp.org/wp-content/uploads/2011/05/Baraiatrice-SPHM-guidebook-care-of-Person-of-Size.pdf

These tools incorporate patient assessment guidelines, scoring tools, algorithms, and equipment guides to provide best-practice guidance in addressing the safe handling and mobility needs of patients, including bariatric patients, their families, and caregivers. These tools and information enable health care providers to plan and implement safe care of patients and promote caregiver safety.

section name header

Skill 9-1

EVIDENCE FOR PRACTICE