You will move persons often. You assist with bed mobility. The Centers for Medicare & Medicaid Services (CMS) defines bed mobility as how a person moves to and from a lying position, turns from side to side, and re-positions in a bed or other furniture. You also position persons in chairs and wheelchairs. You must work carefully to protect yourself and the person from injury.

See Focus on Communication: Safely Moving the Person.

See Promoting Safety and Comfort: Safely Moving the Person.

Focus on Communication

Safely Moving the Person

Moving can be painful after an injury or surgery. Many older persons have painful joints. Provide for comfort and avoid causing pain. You can say:

• “Please tell me when you feel pain or discomfort.”

• “Do you need a pillow adjusted?”

• “Are you comfortable?”

• “How can I make you more comfortable?”

Before any move, explain the procedure. Tell the person what you and your co-workers will do. Also explain what the person needs to do. Do so as you begin the procedure. Also remind the person just before the move.

The procedures in this chapter explain how to move the person on the “count of 3.” Staff move the person at the same time. The person is moved smoothly. One co-worker leads by counting. Decide who will count before the move. Be sure the person and staff know who is leading and what to do. You can say:

We will help you move up in bed. I will count “1, 2, 3.” When I say “3,” push against the bed with your feet and pull up with the trapeze. We will help move your body to the head of the bed when I say “3.”

Promoting Safety and Comfort

Safely Moving the Person

Safety

Many older persons have fragile bones and joints. To prevent injuries:

• Follow the rules of body mechanics (Chapter 17).

• Always have help to move the person.

• Move the person carefully.

• Keep the person in good alignment.

• Position the person in good alignment after the procedure.

• Make sure the face, nose, and mouth are not obstructed by a pillow or other device.

Comfort

To promote mental comfort when moving the person:

• Explain what you are going to do and how the person can help.

• Screen and cover the person to protect the right to privacy.

To promote physical comfort:

• Keep the person in good alignment.

• Do not let the person’s head hit the head-board when he or she is moved up in bed. If the person can be without a pillow, place it upright against the head-board.

• Use pillows to position the person as directed by the nurse and the care plan. If a pillow is allowed under the person’s head, position it under the head and shoulders.

• Use other positioning devices as directed by the nurse and the care plan.

Preventing Work-Related Injuries

Moving procedures involve lifting, awkward postures, and repeated motions. These place you at increased risk for injury. You must prevent work-related injuries during moving procedures. See Chapter 17.

Good body mechanics alone will not prevent injury. The Occupational Safety and Health Administration (OSHA) recommends:

• Minimizing manual lifting in all cases.

• Eliminating manual lifting when possible.

Each person is different. Careful planning is needed to move the person safely. You must know:

• The person’s functional status. Functional status is the person’s ability to perform the activities of daily living (ADL) required to meet basic needs and required for health and well-being. Some persons move without help. Others depend on the staff. Know the person’s functional status before you move a person. See Box 18-1. Tell the nurse about changes in the person’s abilities.

Box 18-1

Functional Status—Bed Mobility

Level 0: Independent. The person can turn and re-position in bed, lie down, and sit up without help. The person may use a bed rail to turn. Staff may raise and lower the bed rail.

Level 1: Supervision. Staff look after, encourage, remind, or cue the person. (To cue means to remind the person what to do.) The person moves without help.

Level 2: Limited Assistance. The person is highly involved. Staff guide but do not lift the person’s arms or legs. The person moves alone. Staff may encourage or cue the person to change positions.

Level 3: Extensive Assistance. The person needs help to turn, re-position, sit up, and move in bed. Two or more staff provide weight-bearing help. (Weight-bearing means to put weight on one’s legs.) To move up in bed, a friction-reducing device is used. To assist, the person bends the knees and pushes with the legs when cued. Or a mechanical lift is used (Chapter 19).

Level 4: Total Dependence. The person is unable to sit up, lie down, turn, or re-position without help. Two or more staff turn, re-position, and move the person. A mechanical lift (Chapter 19) or friction-reducing device is used.

Modified from Centers for Medicare & Medicaid Services: RAI version 3.0 manual, October 2014.

• The number of staff needed. This depends on the person’s height, weight, cognitive function, and functional status. Some persons need no help. Or they just need reminders or help with devices or equipment. Others need help from 1, 2, 3, or more staff.

• What procedure to use. The nurse and care plan tell you what procedure to use.

• The equipment needed. Assist equipment and devices are presented throughout this chapter. The nurse and care plan tell you what to use. Always follow the manufacturer’s instructions. Ask for training to use the equipment and devices safely.

See Focus on Children and Older Persons: Preventing Work-Related Injuries.

See Teamwork and Time Management: Preventing Work-Related Injuries, p. 264.

See Delegation Guidelines: Preventing Work-Related Injuries, p. 264.

See Promoting Safety and Comfort: Preventing Work-Related Injuries, p. 264.

Focus on Children and Older Persons

Preventing Work-Related Injuries

Older Persons

Persons with dementia may not understand what you are doing. They may resist your efforts. The person may shout, 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 the person.

Teamwork and Time Management

Preventing Work-Related Injuries

Patients and residents are moved, turned, and re-positioned often. These procedures are best done by at least 2 staff members.

Friendships are common among co-workers. And some working relationships are better than others. Do not ask for help just from friends or those with whom you work well. Include all co-workers. Do not help just your friends or those with whom you work well. Assist anyone who asks. This includes new staff and those from other units.

Delegation Guidelines

Preventing Work-Related Injuries

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

• The person’s height and weight.

• The person’s functional status (see Box 18-1).

• The person’s physical abilities. Does the person have strength in his or her arms and legs?

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

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

• Any doctor’s orders for moving 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.

Promoting Safety and Comfort

Preventing Work-Related Injuries

Safety

Decide how to move the person before starting the procedure. Ask needed staff to help before you begin. Also plan how to protect drainage tubes or containers connected to the person.

Beds are raised to move persons in bed. This reduces bending and reaching. You must:

• Use the bed correctly.

• Protect the person from falling when the bed is raised.

• Follow the rules of body mechanics (Chapter 17).

Protecting the Skin

Protect the person’s skin during moving procedures. Friction and shearing injure the skin. Both cause infection and pressure ulcers (Chapter 37).

• 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. 18-1). It occurs when the person slides down in bed or is moved in bed.

FIGURE 18-1 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). Drawsheets (Chapter 21) serve as lift sheets (turning sheets). Turning pads (Fig. 18-2), large re-usable waterproof under-pads (Chapter 21), and slide sheets (p. 269) are other friction-reducing devices.

See Focus on Children and Older Persons: Protecting the Skin.

See Focus on Surveys: Protecting the Skin.

Focus on Children and Older Persons

Protecting the Skin

Older Persons

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 when moving and re-positioning persons.

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 (Chapter 19) is needed. Follow the guidelines in Box 18-2 when lifting or moving persons in bed.

Box 18-2

Guidelines for Moving Persons in Bed

• Follow the rules for preventing work-related injuries in Chapter 17.

• Know how much help and what equipment or friction-reducing devices you need. Follow the nurse’s directions and the care plan. The nurse uses the person’s weight as a guide to plan a safe move.

• For persons fully able to assist—staff assistance is not needed. Staff stand by for safety and provide cues as needed.

• For persons partially able to assist :

• If the person weighs less than 200 pounds—2 to 3 staff members and a friction-reducing device are used.

• If the person weighs more than 200 pounds—at least 3 staff members and a friction-reducing device are used.

• For persons unable to assist—a mechanical lift and at least 2 staff members are needed. See “Using a Mechanical Lift” in Chapter 19.

Modified from Occupational Safety and Health Administration: Guidelines for nursing homes: Ergonomics for the prevention of musculoskeletal disorders, Washington, DC, Revised March 2009, Author.

See Focus on Communication: Moving Persons in Bed.

See Delegation Guidelines: Moving Persons in Bed, p. 266.

Focus on Communication

Moving Persons in Bed

The nurse observes the person and asks questions to assess the person’s abilities. Your input is important. Tell the nurse what you have seen, not what you think the person may be able to do. For example:

Nurse: “How have you seen Mr. Boyd move in bed?”

You: “He can lie down and sit up alone.”

Nurse: “Do you give verbal cues or move him in any way?”

You: “I remind him to use the trapeze. Once I remind him, he can do it alone. I also help him turn to his side.”

Nurse: “How do you help him turn to his side?”

You: “He uses the bed rail to turn. I tell him what to do and help move his legs.”

Delegation Guidelines

Moving Persons in Bed

Before moving a person, 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

Raising the Person’s Head and Shoulders

Sometimes you raise the person’s head and shoulders to give care. Simply turning or removing a pillow requires this procedure. You can raise the person’s head and shoulders easily and safely by locking arms with the person. Do not pull on the person’s arm or shoulder. Have help with older persons and with those who are heavy or hard to move. This protects the person and you from injury.

See procedure: Raising the Person’s Head and Shoulders.

Raising the Person’s Head and Shoulders

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. 264

b Moving Persons in Bed

See Promoting Safety and Comfort:

a Safely Moving the Person, p. 263

b Preventing Work-Related Injuries, p. 264

2. Ask a co-worker to assist if needed.

3. Practice hand hygiene.

4. Identify the person. Check the ID (identification) bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.

5. Provide for privacy.

6. Lock (brake) the bed wheels.

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

Procedure

8. Have your co-worker stand on the other side of the bed. Lower the bed rails if up.

9. Ask the person to put the near arm under your near arm and behind your shoulder. His or her hand rests on top of your shoulder. If you are standing on the right side, the person’s right hand rests on your right shoulder (Fig. 18-3, A). The person does the same with your co-worker. The person’s left hand rests on your co-worker’s left shoulder (Fig. 18-4, A).

FIGURE 18-3 Raising the person’s head and shoulders by locking arms with the person. A, The person’s near arm is under the nursing assistant’s near arm and behind the shoulder. B, The nursing assistant’s far arm is under the person’s neck and shoulders. The near arm is under the person’s near arm. C, The person is raised to a semi-sitting position by locking arms. D, The nursing assistant lifts the pillow while the person is in a semi-sitting position.

FIGURE 18-4 Raising the person’s head and shoulders with a co-worker. A, Two nursing assistants lock arms with the person. B, The nursing assistants each have an arm under the person’s head and neck. C, The nursing assistants raise the person to a semi-sitting position. D, One nursing assistant supports the person in the semi-sitting position. The other gives care.

10. Put your arm nearest to the person under his or her arm. Your hand is on the person’s shoulder. Your co-worker does the same.

11. Put your free arm under the person’s neck and shoulders (Fig. 18-3, B). Your co-worker does the same (Fig. 18-4, B). Support the neck.

12. Help the person rise to a sitting or semi-sitting position on the “count of 3” (Figs. 18-3, C and 18-4, C).

13. Use the arm and hand that supported the person’s neck and shoulders to give care (Fig. 18-3, D). Your co-worker supports the person (Fig. 18-4, D).

14. Help the person lie down. Provide support with your locked arm. Support the person’s neck and shoulders with your other arm. Your co-worker does the same.

Post-Procedure

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

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

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

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

19. Unscreen the person.

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

21. Practice hand hygiene.

22. Report and record your observations.

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. 18-5). You move the person up in bed for good alignment and comfort.

FIGURE 18-5 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. 269). 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, p. 268.

See procedure: Moving the Person Up in Bed, p. 268.

Promoting Safety and Comfort

Moving the Person Up in Bed

Safety

This procedure is best done with at least 2 staff members. Work from the side of the bed. Do not pull the person from the head of the bed. Use assist devices as directed by the nurse and the care plan. Ask any questions before you begin the procedure.