12.8.5: Procedure- Turning and Positioning the Patient in Bed

Turning a patient in bed is an important task of the Home Health Aide/Personal Care Aide. It is very important to protect the patient’s skin any time they are turned or moved. Friction (rubbing of two surfaces together, such as the skin rubbing against a sheet) and shearing (when skin sticks to a surface, such as a sheet, and the muscles underneath slide in the direction the body moves) can cause skin breakdown and injury. Friction and shearing can also occur when the patient slides down in bed. To reduce friction and shearing, use a draw sheet or bed pad (these are special linens placed underneath patients to help lift them in bed) when moving a patient. When lifting or moving patients in bed use at least two people to assist as often as possible. Never pull on a patient’s body part to lift or turn them, as this can cause a serious injury.

Patients should be turned every two hours to prevent development of pressure ulcers. There are a number of positions in which patient can be placed. Alternate the positions used to help prevent pressure ulcers and to provide patient comfort. Position pillows under bony areas to prevent pressure ulcers. If patients prefer to stay in one particular position, a pillow should be placed under one buttock or hip to prevent pressure ulcers. This pillow can be rotated to the other side with the next position change. For example, the patient has a pillow placed under their right buttock at 10 am. With the 12 noon turn and position, the pillow can be moved to under the left buttock.

Positions:

• Fowler’s Position: In this position the patient is placed in a sitting up or upright position.
  • This is the position patients should be placed for eating, taking medications, and if they have difficulty with swallowing or breathing.
  • Pillows may be placed behind the head, under each arm, under a hip to lift the buttock from the bed, and one under each leg with heels off the surface of the bed.
• Supine Position: In this position the patient is placed in a lying or reclining position with their back against the bed and their face positioned up.
  • Pillows may be placed behind the head, under a buttock, and one under each leg with heels off the surface of the bed.
• Prone Position: In this position the patient is placed face down with their belly against the bed. Arms should be positioned so they are not underneath the patient. Arms may be gently bent at an angle at the patient’s side.
  • Pillows may be placed under calves, feet, arms, and head for comfort and to prevent pressure ulcers.
• Lateral Position: In this position the patient is placed on one side.
  • Pillows should be placed between their knees, under their head, under the arm that is draped over their top leg, and under the leg that is closest to the bed to keep heels off the surface of the bed.

Pillows should be placed under bony prominences to prevent pressure ulcers.

Examples of Bony Prominences That Are at Risk for Pressure Ulcers:

• Back of the head
• Heels
• Elbows
• Ankles
• Hips
• Sacrum (lower back)
• Coccyx (tailbone)

Before repositioning the patient, Home Health Aides/Personal Care Aides should also offer the use of the restroom, bedpan, or urinal. Patients should also be offered a glass of water at this time to ensure proper hydration. Ensure the patient’s body is in proper alignment once you are done positioning them, and that pillows are used to support body parts.

Procedure: Turning the Patient in Bed

1. Explain the procedure to the patient.
2. Wash and dry hands. Put on gloves as needed.
3. Position yourself on the side of the bed that the patient will be turned to. Adjust the bed to waist height. Lock bed brakes. Lower the head of the bed. This allows gravity to work with, instead of against you. Lower the side rail closest to you. Use proper body mechanics.
4. Provide privacy and warmth for the patient. Keep them covered with a blanket.
5. Ensure safety of the patient while turning. Watch position of the patient’s head and extremities (arms and legs). Never let a patient’s head roll backward or arms and legs to get caught in side rails.
6. Lifting the patient toward the head of the bed: Before turning or positioning a patient, and when patients slide down in bed, Home Health Aides/Personal Care Aides may have to lift them further up toward the head of the bed.
   • For a patient who can assist: Put the head of the bed flat and move any pillows that will be in the path you are moving toward. Lower the side rail on the side you are standing. Use proper body mechanics: stand with your feet hip width apart and slightly bend your knees. Face the patient. The foot closest to where you are moving should be slightly forward and your rear leg slightly backward. Place one arm under the patient’s shoulders and the other under the patient’s thighs. Instruct the patient to bend their knees and push down against the mattress with their feet and hands. You should rock back and forth to begin your motion and start to count out loud. On the count of three, shift your weight to your front leg, and assist the patient to move up in bed, while they push down on the mattress with their hands and feet.
   • Using a draw sheet/bed pad to lift the patient with two people: Put the head of the bed flat and move any pillows that will be in the path you are moving toward. Lower the side rails. Use proper body mechanics: stand with your feet hip width apart and slightly bend your knees. Point the foot closest to the head of the bed in that direction. Your other leg should be slightly behind you. Face the patient. Each person should roll the bed pad on their side and grasp it in their hands. Each person should shift their weight from front to back legs by rocking back and forth and then shift their weight toward their front foot (the direction to which they are going) and on the count of three, slide the patient and draw sheet toward the head of the bed.
   • Using a draw sheet/bed pad to lift the patient with a one person assist: Put the head of the bed flat and move any pillows that will be in the path you are moving toward. Stand behind the head of the bed. Use proper body mechanics: stand with your feet hip width apart and slightly bend your knees. One foot should be slightly in front of the other. Roll and grasp the top of the draw sheet/bed pad on either side of the patient’s shoulders. While pulling the draw sheet up toward you, rock your weight from your front to your back foot. On the count of three, pull the bed pad up toward the head of the bed. If possible, ask the patient to assist by pushing down on the bed with their feet while you lift up.
7. Moving the patient to the side of the bed: Before turning a patient, and when performing procedures such as a bed bath or mouth care, you should position the patient closest to the side of the bed you are on. This prevents you from having to extend your reach, which reduces your personal injury risk. Moving the patient to the side of the bed before turning them also ensures that they will not end up too far on the edge of the other side of the bed, which increases their chance of falling off the bed.
   • Moving the patient in segments: To move the patient in segments, you will first move the upper part of the body, and then the trunk area, and finally the legs and feet. To move the upper part of the body, place the hand closest to the patient underneath their neck and grasp their far shoulder (the shoulder furthest from you) from underneath their body. With your other arm, place your hand under the middle of their back, near their waist area. Gently move their upper body toward you. While moving the patient, watch for proper body mechanics. Rock backward and shift your weight to your back leg. To move their torso, place one arm under their waist and one under their thigh. Rock backward, shift your weight to your rear leg, and move them toward you. To move their legs and feet, place your arms under their thighs and calves. Rock backward and shift your weight to your rear leg. Take care not to let their feet drag or get caught underneath them.
   • Moving the patient with a draw sheet/bed pad with a 2 person assist: To move the patient using a draw sheet/bed pad, roll up the draw sheet/bed pad on the side closest to you. This provides you with a grip with which to move the patient. Another worker should do the same on the other side. On the count of three, rock backward, placing your weight on your rear leg, and pull the patient toward you, lifting slightly so the patient does not drag across the bed.
   • Moving the patient with a draw sheet/bed pad with one person: To move the patient using a draw sheet/bed pad, roll up the draw sheet/bed pad on the side closest to you. This provides you with a grip with which to move the patient. One hand should have the draw sheet/bed pad near the patient’s shoulders, with the other hand grasping the draw sheet near the patient’s hips. On the count of three, rock backward, placing your weight on your rear leg, and pull the patient toward you, using the draw sheet/bed pad to move the patient.
8. To turn the patient toward you: Stand on the side of the bed to which you want to move the patient. Ensure the side rail is up on the side to which the patient is turning from. Lower the side rail on the side closest to you.Cross the patient’s arms over their chest and bend/cross the patient’s leg nearest you over the farthest leg. Stand with your feet about 12 inches apart, bend at the knees, and place one hand on the patient’s shoulder and one on the patient’s hip. Rock backward and shift your weight to your rear leg. Roll the patient toward you.
9. To turn the patient away from you: Stand on the side of the bed opposite of the side you want to move the patient. Ensure the side rail is up on the side to which the patient will be turning. Cross the patient’s arms over their chest. Cross and slightly bend the patient’s leg furthest from you over their lower leg. Stand with your feet about 12 inches apart, bend at the knees, and place one hand on the patient’s shoulder with the other on their hip. Roll the patient in one smooth motion so that their entire body rolls as one. As you roll them, shift your weight from your back to your front leg. You can also use the bed pad to turn the patient toward you by gripping the bed pad near the patient’s shoulder and hip and rolling the patient. Keep the patient in good alignment at all times.
10. Place the patient’s head, arms, and legs correctly. The top knee should be flexed with a pillow between the legs. The ankle and foot should be supported. Support arms and legs as necessary with pillows or rolled towels or blankets. Ensure the patient is not lying on their arm by adjusting their shoulder. Position pillows underneath all bony prominences to prevent pressure ulcer development. A pillow should be placed at the small of their back to prevent them from rolling onto their back.
11. Adjust pillows and head height for comfort. Ensure the patient’s body is properly aligned.
12. Ensure that the patient’s mouth, face, and nose are not obstructed by pillows so they can properly breathe.
13. Return bed to proper safe height (lowest position). Ensure side rails are up for patient safety.
14. Remove your gloves. Wash and dry your hands.
15. Document completion of task and record any changes in condition or behavior. Report and record any observations made about skin condition.