HOLY NAME UNIVERSITY
College of Health Sciences – Department of Nursing
Tagbilaran City, Bohol
Name: ___________________________________ Year and Section: _________
Checklist on Moving a Patient Up in Bed
Procedure Steps 5 4 3 2 1
Assessment
1. Assess physiologic capacity of a patient to move up or turn in bed, and for
special adaptive techniques.
a. Presence of weakness, dizziness, or postural hypotension
b. Level of endurance
c. Patient's proprioception
d. Patient's sensory status
e. Assess for pain and measure level using pain scale from 0-10
f. Patient's cognitive status
g. Patient's level of motivation and readiness
2. Determine if a lift device is needed and determine the number of people
needed. Do not start until all the caregivers are present.
Planning
1. Identify the patient.
2. Introduce self and explain procedure to the patient. Repeat instructions
simply and with continuity to a patient with cognitive dysfunction.
3. Perform hand hygiene.
Implementation
1. Lock the wheels of the bed.
2. Lower the head of the bed and place the patient in supine position.
3. Adjust the height of the bed to waist level.
4. Lower the side rail on the "working" side; keep the side rail up on the
opposite side of the bed.
5. Remove the pillow from under the patient's head and place it at the head
of the bead.
6. Instruct the patient to fold his arms across his chest and cross his
legs/lower extremities.
7. Instruct the patient to flex his neck.
8. Position an assistant on the opposite side of the bed, then each grasps and
rolls/fanfolds the drawsheet close to the patient.
9. Instruct the patient that on the count of three, the two nurses will lift and
move the patient up in bed.
10. Position own feet with a wide base of support while pointing the feet
toward the direction of the move and then flex the knees and the hips.
11. Place own weight on the foot nearest to the foot of the bed, count to three
and then shift weight forward.
12. Repeat until the patient is positioned near the head of the bed.
13. Straighten the draw sheet, place a pillow under the patient's head and
assist the patient into a comfortable position.
14. Place the bed in a low position and raise the side rail.
15. Place the call light in a position where the patient can easily reach it.
Evaluation
1. Evaluate the patient's body alignment and comfort.
2. Evaluate for injuries.
Documentation
1. Document the procedure performed and recorded pertinent findings.
HOLY NAME UNIVERSITY
College of Health Sciences – Department of Nursing
Tagbilaran City, Bohol
Name: ___________________________________ Year and Section: _________
Checklist on Logrolling a Patient
Procedure Steps 5 4 3 2 1
Implementation
1. Lower the side rail on the side where the nurse/s are standing while
keeping the side rail up on the opposite side.
2. Position one staff member at the patient's head and shoulder level.
Position another person at the patient's hips. If three staff members are
needed, position one at the shoulders, one at the waist and the third at thigh
level.
3. One nurse should always support the patient's head, neck and shoulders
during the move. The move is smooth so that the head and hips are always
kept in alignment.
4. Instruct the patient to fold her arms across the chest.
5. Place a pillow between the patient's knees.
6. Use a drawsheet to move the patient away from the side of the bed to
which he/she (patient) will be turned.
7. All nurses position their feet with a wide base of support with one foot
more forward than the other and placing their weight on the forward foot.
8. All nurses bend from the hips and position their hands evenly along the
length of the draw sheet then pull the patient towards them (nurses) in
unison.
9. Raise side rail and moved to the opposite side of the bed.
10. Lower the side rail on the "new" side, face the patient and then one nurse
places his hands on the patient's shoulders and waist while the other one
holds the patient's feet. While another continues to support the patient's head,
neck and shoulders the whole time.
11. Each nurse positions their feet with a wide base of support, with one foot
slightly more forward than the other.
12. The nurse holding the patient's head and neck acts as a team leader and
counts to three and then the nurses turn the patient to the designated side,
turning or moving the patient as a single unit.
13. All nurses flex their knees and hips and shift their weight to the back foot
on the count of three, making sure to support the patient's head as the patient
is being rolled.
14. Position the patient's head with a pillow and also place pillows behind on
the patient's back to maintain the patient in a lateral position.
15. Place the bed in a low position and raise side rails.
16. Place call bell within reach.
Evaluation
1. Evaluate the patient's body alignment and comfort.
2. Evaluate for injuries.
Documentation
1. Document the procedure performed and recorded pertinent findings.
HOLY NAME UNIVERSITY
College of Health Sciences – Department of Nursing
Tagbilaran City, Bohol
Name: ___________________________________ Year and Section: _________
Checklist on Turning a Patient in Bed
Procedure Steps 5 4 3 2 1
Implementation
1. Lower the side rail on the side where the nurse/s are standing while
keeping the side rail up on the opposite side.
2. Move the patient to the side of the bed, opposite from the side the
patient will be turned to, by rolling up/fanfolding the draw sheet close to
the patient's body and grasping the drawsheet at the level of the
shoulders and hips (or holding the patient at the shoulder and hips) and
then pulling it towards nurse.
3. Align the patient's legs and head with his trunk.
4. Raise side rail and transfer to the opposite side.
5. Lower the side rail on the "new side".
6. Position the patient's near arm in abduction and flexion and his far
arm across his/her chest.
7. Flex the patient's far leg at the hips and knees.
8. Place hands at the patient's shoulder and hip or at the drawsheet on the
opposite side.
9. Stand with a wide base of support with one foot slightly more forward
than the other.
10. Place weight on the forward foot and bend from the hips and knees.
11. Shift weight to the back foot while pulling on the draw sheet or on
the patient's shoulders and hip.
12. Position the patient's dependent shoulder forward.
13. Place pillows to maintain the patient in lateral position.
14. Place the bed in a low position and raise the siderails.
15. Place the call light where the patient can easily reach it.
Evaluation
16. Evaluate the patient level of comfort or if the patient feels any
discomfort.
17. Perform hand hygiene.
Documentation
1. Document the procedure performed and record pertinent findings.
NOTE:
1. Time and date the procedure was performed.
2. Any signs of pressure ulcers.
3. Ability of the client to assist in moving and turning and
response of patient regarding the procedure.
Charting/Documentation:
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Rubrics
5 - The student performs the procedure outstandingly
4 - The student performs the procedure very satisfactorily
3 - The student performs the procedure satisfactorily
2 - The student performs the procedure fairly satisfactorily
1- The student performs the procedure unsatisfactorily
Highest Possible Score: ________________
Total Score Earned: __________________
Equivalent Score: ____________________
Clinical Instructor: ___________________
Date Performed: _____________________
Remarks:
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