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Assess client for potential Determine need for protective waterproof incontinence or of excess drainage on pads extra bath blankets on bed. the linen. 2. Check chart for orders or specific Ensures clients safety and use of proper precautions concerning movements and body mechanics. positioning. 3. Explain procedure to the client, Minimizes noting that the client will be asked on cooperation. turn inside and turn over linen. anxiety and promotes
Perform hand hygiene and apply gloves Reduces transmission of microorganism. (gloves are worn only if linen is soiled or there is risk for contact with body secretions). 4. Assemble equipment, and arrange on Assembling all equipment provides for bedside chair or table. smooth procedure and assists in increasing client’s comfort. Remove unnecessary equipment such Placing linen on clean surface minimizes as a dietary tray or items used for spread of infection. hygiene. 1. Draw room curtain around bed or Maintains client’s privacy. close door. 2. Adjust bed height to comfortable Minimizes strain on back. It is easier to working position. remove and apply linen evenly to flat position. Lower any raised side rail on one side Provides easy access to bed and linen. of bed. 3. Loosen top linen at foot of bed. 4. Remove bedspread and blanket separately. 5. If spread and blanket are soiled, placed them in linen bag. 6. If blanket and spread are to be reused, fold them by bringing the top and bottom edges together. Place folded linen over back of chair. It makes linen easier to remove. Reduces transmission of microorganisms. Keep soiled linen away from uniform. Folding method facilitates replacement and fold farthest side over unto nearer bottom edges together again. Minimizes wrinkles.
7. Cover client with bath blanket in Bath blanket provide warmth and keeps the following manner: body parts covered during linen removal. Unfold bath blanket over top sheet. Ask client to hold top edge of bath blanket. If client is unable to help, tuck top of bath blanket under shoulder. Grasp top sheet under bath blanket at client’s shoulders and bring sheet and discard in linen bag. 8. With assistance from another nurse, If mattress slides towards foot of bed when slide mattress toward head of bed. head of bed is raised, it is difficult to tuck in linen. In addition, it is uncomfortable for pressed against or hang over the foot of the bed. 9. Position client on the far side of the Turning client unto side provides space for bed turned onto side and facing placement of clean linen. Side rail ensures away from you. Be sure side rail in client’s safety from toward falls from the front of client is up. Adjust pillow bed surface and help clients in moving. under client’s head. 10. Loosen bottom linens, moving from Prepares for removal of all bottom linen. head to foot. With seam side down Provides maximum work space for placing (facing the mattress), fanfold clean linen. Later when client turns to other bottom sheet and draw sheet toward side, soiled linen can be removed easily. client – first draw sheet then bottom client – first draw sheet then bottom sheet. Tuck edges of linen just under buttocks back and shoulder. Do not fanfold mattress. Pad it is if to be reused. 11. Wipe off any moisture on exposed Reduces transmission of microorganisms. mattress with towel and appropriate disinfectant. 12. Apply clean linen to expose half of Applying linen over bed in successive bed. layers minimizes energy and time used in a. Place clean mattress pad on bed by bed making. folding it lengthwise with center crease in middle of bed. Fanfold top layer over mattress. ( If pas is reused, simply smooth out any wrinkles. ) b. Unfold bottom sheet lengthwise so Proper positioning of linen on one side that center crease is situated ensures that adequate linen will be lengthwise along center of bed. available to cover opposite side of bed.
Fanfold sheet’s top layer toward Keeping seam edges down eliminates center bed alongside the client. irritation to client’s skin. Smooth bottom layer of sheet over mattress, and bring edge over closest side of mattress. Pull fitted sheet smoothly over mattress ends. Allow edge of flat unfitted sheet to hang about 25 cm (10 in) over mattress edge. Lower hem of bottom flat sheet should lie seen down and even with bottom edge of mattress. 13. Miter bottom flat sheet at head of bed. 14. Face head of bed diagonally. Place hand from head of bed under top corner of mattress, near mattress edge and lift. 15. With other hand, tuck top edge of sheet smoothly under mattress so that side edges of sheet above and below mattress would meet if brought together. 16. Face side of bed and pick up top edge of sheet at approximately 45 cm (18 in) from top of mattress. 17. Lift sheet, and lay it on top of mattress to form a lower base triangular fold, with lower base of triangular fold, with lower base of triangle even with mattress side edge. 18. Tuck lower edge of sheet, which is hanging free below the mattress, under mattress. Tuck with pals down, without pulling triangular fold. 19. Hold portion of sheet covering side of mattress to place with one hand. With the other hand pick up top of triangular linen fold and bring it down over side of mattress. Tuck remaining portion of sheet under mattress. Tuck remaining portion of sheet under Ensures secure flat sheet will not loosen easily.
Mitered corner cannot be loosened easily even if client moves frequently in bed.
Folds of linen are source of irritation.
mattress, moving toward foot of bed. Keep linen smooth. 20. (Optional) Open drawsheet so that it unfolds in half. Lay centerfold along middle of bed lengthwise, and position sheet so that it will be under the client’s buttocks and torso. Fanfold top layer toward client, with edge along client back. Smooth bottom layer out over mattress, and tuck excess edge under mattress. 21. Place waterproof pad over draw sheet, with centerfold against client’s side. Fanfold top layer toward client. 22. Have client roll slowly toward you, over the layers of linen. Raise side rail on working side, and go to other side of bed. 23. Have client roll slowly toward you, over the layers of linen. Raise side rail on working side, and go to other side of bed. 24. Lower side rail. Assist client in positioning on other side, over folds of linen. Loosen edges of soiled linen from under mattress. 25. Remove soiled linen by folding it into a bundle or square, with soiled side turned in. Discard in linen bag. If necessary, wipe mattress with antiseptic solution, and dry mattress surface before applying new linen. 26. Pull clean, fanfold linen smoothly over edge of mattress from head to foot of bed. 27. Assist client in rolling back into supine position. Reposition pillow. 28. Pull fitted sheet smoothly over mattress ends. Miter top corner of bottom sheet. When tucking corner, be sure that sheet is smooth and free of wrinkles. 29. Facing side of bed, grasp remaining Drawsheet is used to lift and reposition. Placement under client’s torso distributes most client’s body weight over sheet.
Protects bed linen from being soiled.
Position client for removal and placement of linens. Maintain client’s safety and body alignment during turning.
Expose opposite side of bed for removal of soiled linen and placement of clean linen. Makes linen easier to remove. Reduces transmission of microorganism.
Smooth linen will not irritate the client’s skin. Maintains client’s comfort. Wrinkles and folds can cause irritation to skin.
Proper use of body mechanics while
edge of bottom flat sheet. Grasp edge sheet. Lean back; keep back straight and pull while tucking excess linen under mattress. Proceed from head to bed. (Avoid lifting mattress during tucking to ensure fit.) 30. Smooth fan folded draw sheet out over bottom sheet. Grasp edge of set of palms down; lean back; and tuck sheet mattress. Tuck from middle to top and then to bottom lifting mattress during tucking to ensure fit.) 31. Place top sheet over clients with centerfold lengthwise down middle of bed. Open sheet from head to foot, and unfold over client. 32. Ask client to hold clean top sheet, or tuck sheet around client’s shoulders. Remove bath blanket and discard in linen bag. 33. Place blanket on bed, unfolding it so that crease runs length wise along middle of bed. Unfold blanket to cover client. Top edge should be parallel with edge of top sheet and 15 to 20 cm (6 to 8 in) from top sheet’s edge. 34. Place spread over bed according to step 35. Be sure that top edge of spread extends about 2.5 cm (1in) above blanket’s edge. Tuck top edge of spread over and under top edge of blanket. 35. Make cuff by turning edge of top sheet down over top edge of blanket and spread. 36. Standing on one side at foot of bed, lift mattress corner slightly with one hand and tuck linens under mattress. Top sheet and blanket are tucked under together.
tucking linen prevents injury.
Tucking first at top or bottom may under pull sheet sideways, causing poor fit.
Sheet should be equally distributed over bed by correctly positioning centerfold.
Sheets prevent exposure of body parts. Having client hold sheet encourages client’s participation in care. Blanket should be placed to cover client completely and provide adequate warmth.
Gives bed neat appearance.
Protects client’s face from rubbing against tight, fleeting bed sheets. Makes neat-appearance bed.
Be sure that linens are loose enough to Pressure ulcers can develop on client’s toes allow movement of client’s feet. Making a and heels from feet rubbing against tight-
horizontal toe pleat is an option.
fitting bed sheets.
37. Make modified mitered corner with Ensures top covers will not loosen easily. top sheet, blanket, and spread. Pick up side edge of top sheet, blanket and spread approximately 45 cm (18in) from foot of mattress. Lift linen to form triangular fold, and lay it at bed. Tuck lower edge of sheet, which is hanging free below mattress, under mattress. Do not pull triangular fold. Pick up triangular fold, and bring it down Secures top linen but keeps even edge of over mattress while holding linen on place blanket and top sheet draped over mattress. along side of mattress. Do not tuck tip of triangle. 38. Raise side rail. Make other side of bed; spread sheet, blanket and bedspread out evenly. Fold top edge of spread over blanket and make cuff will top edge spread over blanket and make cuff with top sheet; make modified mitered corner at foot of bed. 39. Change pillowcase: a. Have client raise head. While supporting neck with one hand, remove pillow. Allow client to lower head. b. Remove soiled case by grasping pillow at open end with one hand, remove pillow. c. Grasp clean pillowcase at center of closed end. Gather case, turning it inside out over the hand holding it. With the same hand, pick up middle of one end of the pillow. Pull pillowcase down over pillow with the other hand. d. Be sure pillow corners fit evenly into corners of pillow case. Place pillow under client’s head. 40. Place call light within client’s reach and return bed to comfortable Side rails protects from accidental fall.
Support of neck muscles prevents injury during flexion and extension of neck.
Pillows slide out easily, thus minimizing contact with soiled linen. Eases sliding of pillowcase over pillow.
Poorly fitting case constricts fluffing and expansion of pillow and interferes with client comfort. Ensures client safety and comfort.
position. 41. Open room curtains, and rearrange furniture. Place personal items within easy reach on over-bed table or bedside stand. Return bed to comfortable height. 42. Discard dirty linen in hamper or chute and perform hand hygiene. 43. As if client feels comfortable. 44. Inspect skin for areas of irritation. 45. Observe client for signs of fatigue, dyspnea, pain, or discomfort.
Promote sense of well-being.
Prevents transmission of microorganisms. Ensures bed linens are clean and smooth. Folds in linens can cause pressure on skin. Provides you with data about client’s level of activity tolerance and ability to participate in other procedures.
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