• Use drawsheets (Chapter 15), turning pads (p. 176), or large waterproof pads (Chapter 15). Other friction-reducing devices include sliding boards, slide sheets, and low-friction mattress covers.

• Get a good hand-hold. Roll up drawsheets, turning pads, and large waterproof pads. Or use assist devices with handles.

• Kneel on the bed or stretcher. This prevents extended reaches and bending your back.

• Have staff on both sides of the bed or other surface. Move the person on the “count of 3.” Use a smooth, push-pull motion. Do not reach across the person.

Transfer Belts

• Keep the person as close to you as possible.

• Avoid bending, reaching, or twisting to:

• Apply or remove a belt.

• Lower the person to the chair, bed, toilet, or floor.

• Help the person walk.

• Use a gentle rocking motion to help the person stand. The rocking motion gives strength and force as you pull the person to the standing position.

• See Chapter 10.

Stand and Pivot Transfers

• Use assist devices as directed. Follow the care plan.

• Use a transfer belt with handles.

• Keep your feet at least shoulder-width apart.

• Lower the bed so the person can place his or her feet on the floor.

• Plan the transfer so the person’s strong side moves first.

• Get the person close to the edge of the bed or the chair. Ask the person to lean forward as he or she stands.

• Block the person’s weak leg with your legs or knees. If the position is awkward:

• Use a transfer belt with handles.

• Straddle your legs around the person’s weak leg.

• Bend your legs. Do not bend your back.

• Pivot with your feet to turn.

• Use a gentle rocking motion to help the person stand. The rocking motion gives strength and force as you pull the person to the standing position.

Lifting or Moving the Person in Bed

• Adjust the height of the bed, stretcher, or other surface to waist level.

• Lower the bed rail or the stretcher side rail.

• Work on the side where the person will be closest to you.

• Place equipment or other items close to you at waist level.

• Use drawsheets, turning pads, large waterproof pads, or slide sheets.

Transporting the Person and Equipment

• Push, do not pull.

• Keep the load close to your body.

• Use an upright posture.

• Push with your whole body, not just your arms.

• Move down the center of the hallway. This helps avoid collisions.

• Watch out for door handles and high floor thresholds. These can cause abrupt stops.

Transferring the Person From the Floor

• Use a mechanical lift if possible (p. 191). If not, place a sling, blanket, drawsheet, cot, or other assist device under the person as directed by the nurse.

• Position at least 2 staff members on each side of the person. More staff is needed if the person is large.

• Bend your knees, not your back. Do not twist.

• Roll the person onto his or her side to position the assist device. Do not reach across the person.

• Lower the hoist (for a mechanical lift) to attach the sling. The hoist is low enough to easily attach the sling.

• Do the following for a manual lift.

• Kneel on 1 knee.

• Grasp the blanket, drawsheet, cot, or other device.

• Lift smoothly with your legs as you stand on the “count of 3.” Do not bend your back.

Modified from Cal/OSHA: A back injury prevention guide for health care providers, Sacramento, Calif, 1997, Author; and referenced in Occupational Safety and Health Administration: Ergonomics: guidelines for nursing homes, Washington, DC, 2009, Author.

• Minimizing manual lifting in all cases.

• Eliminating manual lifting when possible.

To safely move and transfer the person, the nurse and health team determine:

• The person’s dependence level. See Box 14-2, p. 172.

Box 14-2

Levels of Dependence

Level 4: Total Dependence. The person cannot help with the transfer. Staff perform the task or procedure.

• The person is lifted and transferred with a full-sling mechanical lift (Fig. 14-1).

Level 3: Extensive Assistance. The person can bear some weight, can sit up with help, and may be able to pivot to transfer.

• The person is lifted and transferred with a mechanical lift—full-sling mechanical lift or stand-assist lift (Fig. 14-2).

Level 2: Limited Assistance. The person is highly involved in the moving or transfer procedure. Some help is needed moving the legs. The person can stand (bear weight). The person has upper body strength and can sit up. He or she can pivot transfer.

• Stand-assist devices may be needed. Some attach to the bed or chair (Fig. 14-3). Others include walkers (Chapter 23) and transfer belts with handles (Chapter 10).

• Sliding boards are useful for transfers to and from beds and chairs (Fig. 14-4).

Level 1: Supervision. The staff need to look after, encourage, or remind the person what to do.

• The devices for Level 2 may be needed.

Level 0: Independent. The person walks without help. Sometimes the person needs limited assistance.

• Mechanical assistance is not normally required for transfers, lifting, or re-positioning.

Modified from Ergonomics Technical Advisory Group: Patient care ergonomics resource guide: safe patient handling and movement, revised August 31, 2005, Patient Safety Center of Inquiry (Tampa, Fla), Veterans Health Administration, and Department of Defense.

• The amount of help needed and the number of staff needed.

• What procedure to use.

• The equipment needed.

See Focus on Older Persons: Preventing Work-Related Injuries, p. 173.

See Delegation Guidelines: Preventing Work-Related Injuries, p. 173.

See Promoting Safety and Comfort: Preventing Work-Related Injuries, p. 173.

Focus on Older Persons

Preventing Work-Related Injuries

Persons with dementia may not understand what you are doing. They may resist your moving and transfer efforts. The person may shout at you, grab you, or try to hit you. Always have a co-worker help you. Do not force the person. The person’s care plan has measures for safe care. For example:

• Proceed slowly.

• Use a calm, pleasant voice.

• Divert the person’s attention. For example, let the person hold a washcloth or other soft object. This helps distract the person and keeps the hands busy.

Tell the nurse at once if you have problems moving or transferring the person.

Delegation Guidelines

Preventing Work-Related Injuries

Many tasks involve moving and transferring persons. Before doing so, you need this information from the nurse and the care plan.

• The person’s height and weight.

• The person’s dependence level (see Box 14-2).

• The person’s physical abilities. Can the person sit up, stand up, or walk without help? Does the person have strength in his or her arms?

• If the person has a weak side. If yes, which side?

• If the person has a medical condition that increases the risk of injury? Dizziness, confusion, hearing or vision problems, recent surgery, and fragile skin are examples.

• Any doctor’s orders for moving or transferring the person.

• The person’s ability to follow directions.

• If behavior problems are likely. Combative, agitated, uncooperative, and unpredictable behaviors are examples.

• The amount of assistance needed.

• The number of staff needed to complete the task safely.

• What procedure to use.

• What equipment to use.

Protecting the Skin

Protect the person’s skin during moving and transfer procedures. Friction and shearing injure the skin. Both cause infection and pressure ulcers (Chapter 25).

• Friction is the rubbing of 1 surface against another. When moved in bed, the person’s skin rubs against the sheet.

• Shearing is when the skin sticks to a surface while muscles slide in the direction the body is moving (Fig. 14-5). It occurs when the person slides down in bed or is moved in bed.

FIGURE 14-5 Shearing. When the head of the bed is raised to a sitting position, skin on the buttocks stays in place. However, internal structures move forward as the person slides down in bed. This pinches the skin between the mattress and the hip bones.

To reduce friction and shearing when moving the person in bed:

• Roll the person.

• Use friction-reducing devices. Such devices include a lift sheet (turning sheet). A cotton drawsheet (Chapter 15) serves as a lift sheet (turning sheet). Turning pads, large waterproof pads (Chapter 15), and slide sheets (p. 176) are other friction-reducing devices.

See Focus on Older Persons: Protecting the Skin, p. 174.

See Focus on Surveys: Protecting the Skin, p. 174.

Focus on Older Persons

Protecting the Skin

Older persons are at great risk for shearing. Their fragile skin is easily torn. Protect the skin from injury.

Ask a co-worker to help you move older persons. Use a friction-reducing device. Move older persons carefully and gently.

Persons with dementia may try to resist your efforts. Do not force the person. Work slowly. Use a calm voice. Divert the person’s attention if necessary.

Focus on Surveys

Protecting the Skin

Shearing and friction can easily damage the skin. Surveyors will observe the measures taken by staff to prevent or reduce shearing and friction during transfers and re-positioning.

Moving Persons in Bed

Some persons can move and turn in bed. Others need help from at least 1 person. Those who are weak, unconscious, paralyzed, or in casts need help. Sometimes 2 or 3 people or a mechanical lift is needed.

• Level 4: Total Dependence—a mechanical lift or friction-reducing device and at least 2 staff members

• Level 3: Extensive Assistance—a mechanical lift or friction-reducing device and at least 2 staff members

• The person weighs less than 200 pounds—2 to 3 staff members and a friction-reducing device

• The person weighs more than 200 pounds—at least 3 staff members and a friction-reducing device

See Delegation Guidelines: Moving Persons in Bed.

Delegation Guidelines

Moving Persons in Bed

Before moving a person in bed, you need this information from the nurse and the care plan.

• What procedure to use

• The number of staff needed to safely move the person

• Position limits and restrictions

• How far you can lower the head of the bed

• Any limits in the person’s ability to move or be re-positioned

• What pillows you can remove before moving the person

• What equipment is needed—trapeze, lift sheet, slide sheet, mechanical lift

• How to position the person

• If the person uses bed rails

• What observations to report and record:

• Who helped you with the procedure

• How much help the person needed

• How the person tolerated the procedure

• How you positioned the person

• Complaints of pain or discomfort

• When to report observations

• What patient or resident concerns to report at once

Moving the Person Up in Bed

When the head of the bed is raised, it is easy to slide down toward the middle and foot of the bed (Fig. 14-6). You move the person up in bed for good alignment and comfort.

FIGURE 14-6 A person in poor alignment after sliding down in bed.

You can sometimes move light-weight adults up in bed alone if they assist using a trapeze. However, it is best done with help and an assist device (p. 176). For heavy, weak, and older persons, 2 or more staff members are needed. Always protect the person and yourself from injury.

See Promoting Safety and Comfort: Moving the Person Up in Bed.

See procedure: Moving the Person Up in Bed.

Promoting Safety and Comfort

Moving the Person Up in Bed

Safety

This procedure is best done with at least 2 staff members. Use an assist device as directed by the nurse and the care plan. Ask any questions before you begin the procedure.

Perform the procedure alone only if:

• The person is small in size.

• The person can follow directions.

• The person can assist with much of the moving.

• The person uses a trapeze.

• The person can push against the mattress with his or her feet.

• The nurse says it is safe to do so.

• You are comfortable doing so.

Moving the Person Up in Bed

Quality of Life

• Knock before entering the person’s room.

• Address the person by name.

• Introduce yourself by name and title.

• Explain the procedure before starting and during the procedure.

• Protect the person’s rights during the procedure.

• Handle the person gently during the procedure.

Pre-Procedure

1. Follow Delegation Guidelines:

a. Preventing Work-Related Injuries, p. 173

b. Moving Persons in Bed

See Promoting Safety and Comfort:

a. Assisting With Moving and Transfers, p. 170

b. Preventing Work-Related Injuries, p. 173

c. Moving the Person Up in Bed

2. Ask a co-worker to help you.

3. Practice hand hygiene.

4. Identify the person. Check the ID (identification) bracelet against the assignment sheet. Also call the person by name.

5. Provide for privacy.

6. Lock the bed wheels.

7. Raise the bed for body mechanics. Bed rails are up if used.

Procedure

8. Lower the head of the bed to a level appropriate for the person. It is as flat as possible.

9. Stand on 1 side of the bed. Your co-worker stands on the other side.

10. Lower the bed rails if up.

11. Remove pillows as directed by the nurse. Place a pillow against the head-board if the person can be without it.

12. Stand with a wide base of support. Point the foot near the head of the bed toward the head of the bed. Face the head of the bed.

13. Bend your hips and knees. Keep your back straight.

14. Place 1 arm under the person’s shoulder and 1 arm under the thighs. Your co-worker does the same. Grasp each other’s forearms (Fig. 14-7).

FIGURE 14-7 A person is moved up in bed by 2 nursing assistants. Each has 1 arm under the person’s shoulders and the other under the thighs. They have locked arms under the person. The person grasps the trapeze and flexes the knees. The nursing assistants shift their weight from the rear leg to the front leg as the person is moved up in bed.

15. Ask the person to grasp the trapeze.

16. Have the person flex both knees.

17. Explain that:

a. You will count “1, 2, 3.”

b. The move will be on “3.”

c. On “3,” the person pushes against the bed with the feet if able. And the person pulls up with the trapeze.

18. Move the person to the head of the bed on the count of “3.” Shift your weight from your rear leg to your front leg (see Fig. 14-7). Your co-worker does the same.

19. Repeat steps 12 through 18 if necessary.

Post-Procedure

20. Put the pillow under the person’s head and shoulders.

21. Position the person in good alignment. Raise the head of the bed to a level appropriate for the person.

22. Provide for comfort. (See the inside of the front cover.)

23. Place the call light and other needed items within reach.

24. Lower the bed to a safe and comfortable level appropriate for the person. Follow the care plan.

25. Raise or lower bed rails. Follow the care plan.

26. Unscreen the person.

27. Complete a safety check of the room. (See the inside of the front cover.)

28. Practice hand hygiene.

29. Report and record your observations.

Moving the Person Up in Bed With an Assist Device

You use assist devices to move some persons up in bed. Such assist devices include a drawsheet (lift sheet), flat sheet folded in half, turning pad (Fig. 14-8), slide sheet (Fig. 14-9), and large waterproof pad. With these devices, the person is moved more evenly. And shearing and friction are reduced.

Place the device under the person from the head to above the knees or lower. At least 2 staff members are needed. This procedure is used for most patients and residents. It is used:

• Following the guidelines for “Moving Persons in Bed,” p. 174

• For persons recovering from spinal cord surgery or spinal cord injuries

• For older persons

See Promoting Safety and Comfort: Moving the Person Up in Bed With an Assist Device.

See procedure: Moving the Person Up in Bed With an Assist Device.

Promoting Safety and Comfort

Moving the Person Up in Bed With an Assist Device

Safety

Not all waterproof pads are used as assist devices. Disposable, single-use underpads are not strong enough to hold the person’s weight during the move. Re-usable underpads are stronger. For safety, the underpad must:

• Be strong enough to support the person’s weight.

• Extend from under the person’s head to above the knees or lower.

• Be wide enough for you and other staff to get a firm grip for the lift.

Ask the nurse if the person’s underpad is safe as an assist device.

To use a slide sheet, place it under the person. See procedure: Making an Occupied Bed in Chapter 15 for this step. After the procedure, remove the slide sheet. Otherwise the person is in danger of sliding down in bed or off the bed.

Moving the Person Up in Bed With an Assist Device

Quality of Life

• Knock before entering the person’s room.

• Address the person by name.

• Introduce yourself by name and title.

• Explain the procedure before starting and during the procedure.

• Protect the person’s rights during the procedure.

• Handle the person gently during the procedure.

Pre-Procedure

1. Follow Delegation Guidelines:

a. Preventing Work-Related Injuries, p. 173

b. Moving Persons in Bed, p. 174

See Promoting Safety and Comfort:

a. Assisting With Moving and Transfers, p. 170

b. Preventing Work-Related Injuries, p. 173

c. Moving the Person Up in Bed, p. 174

d. Moving the Person Up in Bed With an Assist Device

2. Ask a co-worker to help you.

3. Practice hand hygiene.

4. Identify the person. Check the ID bracelet against the assignment sheet. Also call the person by name.

5. Provide for privacy.

6. Lock the bed wheels.

7. Raise the bed for body mechanics. Bed rails are up if used.

Procedure

8. Lower the head of the bed to a level appropriate for the person. It is as flat as possible.

9. Stand on 1 side of the bed. Your co-worker stands on the other side.

10. Lower the bed rails if up.

11. Remove pillows as directed by the nurse. Place a pillow against the head-board if the person can be without it.

12. Stand with a wide base of support. Point the foot near the head of the bed toward the head of the bed. Face the head of the bed.

13. Roll the sides of the assist device up close to the person. (Note: Omit this step if the device has handles.)

14. Grasp the rolled-up assist device firmly near the person’s shoulders and hips (Fig. 14-10). Or grasp it by the handles. Support the head.

FIGURE 14-10 A drawsheet is used to move the person up in bed. It extends from the person’s head to above the knees. Rolled close to the person, the drawsheet is held near the shoulders and hips.

15. Bend your hips and knees.

16. Move the person up in bed on the count of “3.” Shift your weight from your rear leg to your front leg.

17. Repeat steps 12 through 16 if necessary.

18. Unroll the assist device. (Note: Omit this step if the device has handles.) Remove the slide sheet if used.

Post-Procedure

19. Put the pillow under the person’s head and shoulders.

20. Position the person in good alignment. Raise the head of the bed to a level appropriate for the person.

21. Provide for comfort. (See the inside of the front cover.)

22. Place the call light and other needed items within reach.

23. Lower the bed to a safe and comfortable level appropriate for the person. Follow the care plan.

24. Raise or lower bed rails. Follow the care plan.

25. Unscreen the person.

26. Complete a safety check of the room. (See the inside of the front cover.)

27. Practice hand hygiene.

28. Report and record your observations.

Moving the Person to the Side of the Bed

Re-positioning and care procedures require moving the person to the side of the bed. Move the person to the side of the bed before turning. Otherwise, after turning, the person lies on the side of the bed—not in the middle.

Sometimes you have to reach over the person. During a bed bath is an example. You reach less if the person is near you.

In one method, the person is moved in segments (Fig. 14-11). Sometimes you can do this alone. With at least 1 co-worker, use a mechanical lift (p. 191) or an assist device: