Clinical skills: bed making and
patient positioning
Abstract
Providing a clean, comfortable bed and positioning a patient in the
optimum posture for prevention of complications and to enable
maximum independence are fundamental nursing skills. Bed making
is a daily routine that requires practical and technical skills. Selecting
the correct posture for a patient in bed or in a chair is essential for
physiological functioning and recovery. In this article bed making is
described, as are positioning and re-positioning in relation to patients
in bed, armchairs and wheelchairs. Infection control and moving and
handling issues are also considered
Key words: Bedmaking n Positioning n Moving and handling
P
roviding a comfortable bed and positioning a patient
to prevent pressure ulcers or to assist breathing are
important ways that nurses can promote comfort.
These are fundamental nursing skills that require
practical ability and are vital in enhancing a patient’s physical,
social and psychological wellbeing. In this article the procedure
for bedmaking will be described. Positioning patients in bed
and in chairs to promote optimum function will be discussed.
Moving and handling issues will be considered in relation to
repositioning patients.
Bedmaking
Bedmaking is a daily routine in nursing but for a patient who
is in bed for all or part of the day, a comfortable bed and
appropriate bedding are essential (Burrows and Baillie, 2005).
Bedmaking is an example of how nursing is a combination
of the practical (the procedure) and the technical (the
promotion of patient comfort and the prevention of cross
infection) (Gowin, 2001). However, there is very little
research-based literature about this fundamental skill.
The bed
Many hospitals have introduced electrically or manually
operated four-section profiling beds where the press of a
control button is all that is needed to sit a patient up. These
improve patient comfort and allow some patients to adjust
their own position (Rush, 2004), allowing for a variety of
Glynis Collis Pellatt is Senior Lecturer, Faculty of Health and Social
Science, Aylesbury Vale Education Centre, Stoke Mandeville Hospital,
Aylesbury, Buckinghamshire
Accepted for publication: September 2006
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Glynis Collis Pellatt
postures.The advantages of profiling beds are that they reduce
back problems for staff and they stop the patient sliding down
the bed, thereby reducing shearing forces on the sacrum and
heels helping to prevent pressure ulceration (Maylor, 2001).
However, in the community, patients may be nursed
on their divan bed which has no variable height or back
rest. This poses challenges for positioning the patient and
increases the risk of back problems for carers (Rush, 2004).
The bed may have a standard foam hospital mattress, a
pressure-relieving replacement mattress or a mattress overlay
(Arblaster, 1999; Pellatt, 2005).
Making beds
Beds will need to be made both with and without patients in
them. Table 1 describes making an unoccupied and occupied
bed. It is more time efficient (and safer for the patient when
making an occupied bed) to do this task in pairs (Gowin,
2001). The need for changing of bed linen should be assessed
and linen changed when necessary rather than as a daily
ritual (Westfall and Burrow, 1997).
Patient positioning
Correct therapeutic positioning of patients is essential to
maximize their physiological functioning and recovery.
Poor positioning can compromise a patient’s airway, cause
joint dislocations, displacement of fractures, peripheral nerve
damage, spasm and pressure ulcers (Hawkins et al, 1999;
Jarrett, 2004; Griffiths and Gallimore, 2005).
Basic positions in bed
n The supine position
In the supine position the patient is placed on his back with
the spinal column in a straight line and legs parallel to the bed
(Jacobs, 1994a; Griffiths and Gallimore, 2005). See Figure 1
n The lateral position
In the right lateral position the patient lies on his right side
with the left side upward. In the left lateral position the
patient lies on his left side with the right side upward (see
Figure 2). The hip of the non-weight bearing leg is flexed
to ease pressure over bony prominences. A pillow or foam
wedge along the thoracolumbar spine will help to keep the
patient in alignment. A pillow between the legs will relieve
pressure on the knees. A pillow under the non-weight-
bearing arm may also be used to maintain body alignment
(Jacobs, 1994a; Griffiths and Gallimore, 2005). Stroke patients
may be better lying on their paretic (paralysed) side than
their non-paretic side to control muscle tone (Rowat, 2001)
British Journal of Nursing, 2007, Vol 16, No 5

n The prone position
In the prone position the patient is placed face down on the
bed (see Figure 3). The patient will need a pillow under his
head or a wedge under the chest for comfort. Pillows under
the shins will help prevent pressure on the upper area of the
feet and toes (Jacobs, 1994b; McEwan, 1996; Griffiths and
Gallimore, 2005).
It has been suggested that placing people with acute
respiratory distress syndrome (ARDS) in the prone position
helps to improve gas exchange in some patients (Wong, 1999;
Breiburg et al, 2000; Essat, 2005). However, Broccard (2003)
points out that there needs to be more research on how often
patients should be turned prone and how long they should
be kept prone.
Positioning patients
Before moving and repositioning a patient, an ergonomic
risk assessment must be undertaken (Pellatt, 2005):
1. Task
2. Individual capability
3. Load
4. Environment.
Where necessary, the appropriate equipment must be used
to move the patient if she is unable to move herself. The
European Pressure Ulcer Advisory Panel (EPUAP, 1998) state
that devices to assist manual handling should be used when
repositioning patients to minimize shear forces. Slide sheets
are particularly effective for turning patients in bed and they
considerably reduce friction. If the slide is being used on top
of a pressure-relieving mattress it may need to be put into
static mode to provide a firm working surface (Rush, 2004).
A mechanical hoist may be appropriate for repositioning
some patients as it enables a clear lift and minimizes shear
and friction (Maylor, 2001).
Moving and repositioning
Healthy individuals will change their posture every
11.6 minutes when asleep (Hawkins et al, 1999). If a
patient is unable to carry out this function herself, she may
need assistance. Patients are turned regularly for pressure
relief, although the use of pressure-relieving systems is
replacing regular repositioning in some cases (Arblaster,
1999). However, patients are also repositioned regularly to
prevent chest infections, osteoporosis, limb oedema, deep
vein thrombosis and contractures (Hawkins et al, 1999).
Not all patients will be nursed flat in bed, for example
patients who have difficulty breathing (dyspnoea) need to
sit up in bed or in an armchair and should be well supported
with pillows to optimize ventilation (Baillie et al, 2005).
For patients with acute brain injury and raised intracranial
pressure, elevating the head to between 45 and 90 degrees
will reduce the intracranial pressure (Rowat, 2001).
For patients with severe spasm, simple positioning
strategies can help to reduce the level of spasticity. Sitting
patients in flexion after they have been lying in extension
at night can break the extensor pattern. Pillows, wedges
or T-rolls under the lower limbs to put them in flexion
can help reduce adductor spasticity and extensor spasm
(Jarrett, 2004).
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CLINICAL SKILLS
Table 1. Bed making
Unoccupied bed
Equipment: Two sheets (one fitted if available), or a duvet. The sheets should be
folded in half lengthwise. Check that the sheet is not torn or damaged, pillowcase,
laundry bag – white linen or clear plastic bags are for used and soiled linen. For
infected linen, a water soluble bag with a red outer bag is used (Arrowsmith,
2005).
Preparation:
Wash hands and put on a plastic apron
Put the bed brakes on
Make the bed level and raise the bed to a comfortable working height for both nurses
The bed may have a pull-out rack at the bottom of the bed or you may need to use
two chairs for the bedding
Move other furniture away from the bed so that you have space to work in
Procedure:
Remove the pillowcase and place it in the laundry bag
Lift the mattress slightly and working around the bed untuck the bedding
Carefully remove the bed-linen that is going to be reused and place on the rack or
chair.
Put soiled linen in the laundry bag.
To prevent cross-infection do not flap the linen about, hold it against your clothing
or drop it on the floor
Place the bottom sheet with its centre fold in the middle of the mattress. If you do
not have a fitted sheet align the end of the sheet with the mattress and mitre the
top corner (hospital corner):
Pull the sheet tight then push it under the mattress at the head of the bed.
Where the sheet is hanging down at the side edge of the mattress lift it out
so it continues along the plane of the bed. Hold it with one hand and take
your other hand and tuck in the bottom edge of the sheet hanging below the
mattress. Drop the top edge and tuck it under the mattress
Repeat this with the other three corners then tuck in what is left of the sheet on
the sides. Make sure there are no wrinkles in the sheet that could cause pressure
ulcers.
If a duvet is being used this will be placed on the bed.
Otherwise, sheets, blankets and bedspread will be put on the bed. Allow enough
sheet at the top to form a cuff over the blankets and bedspread
Make a 3 inch pleat in the top bedding to allow room for the patient’s feet to
prevent pressure and foot drop
Tuck in the sheet and other bedding at the foot of the bed and mitre the bottom
corners
Fold the top sheet over the sheets and spread to form a cuff
Put the pillow into a clean case and place on the bed with the open end away
from the door for neatness
Lower the bed, replace furniture, dispose of the linen, remove apron and wash
hands.
(Continued)
In the operating theatre, patients will be positioned in a
variety of ways for different types of surgery, allowing access
to the operation site without compromising organ function
or patient safety. There are attachments available for the
operating table to aid positioning and minimize the risks
of harm to the patient’s respiration, circulation, peripheral
nerves and skin. These include limb supports and head
supports (Griffiths and Gallimore, 2005).
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Table 1. Bed making (continued)
Occupied bed
When making a bed with a patient in it, the patient will need to be rolled from
side to side to enable the bottom sheet to be removed and a clean one inserted:
Roll the patient on to the far side and support his/her head with a pillow.
Roll the soiled sheet towards the patients back.
Place a clean sheet on the bed with its centre fold in the middle of the mattress.
Concertina the remaining sheet toward the patient
Roll the patient to the clean side of the bed
Remove the soiled sheet and then pull the clean sheet taut.
If the patient is unable to be rolled on his side, the clean sheet can be put in from
the head of the bed in a similar way. In this case the patient will be asked to move
down the bed while the soiled sheet is rolled toward their back and the clean one
inserted. The patient will then be asked to move back up the bed on to the clean
area while the soiled sheet is removed and the clean one pulled taut.
If the patient is not able to do this himself then appropriate equipment will need to
be used.
At the end of the bed making make sure the patient is comfortable and can reach
his locker, call bell, etc.
Adapted from Ambrose and Quinless (2004)
Positioning patients in chairs
Healthy human beings are able to stand and sit to carry out
daily living activities (Collins, 1999). However, some immobile
patients are unable to stand and they spend long periods of
time sitting, often in the same position, unable to reposition
themselves. The National Institute for Health and Clinical
Figure 1. Supine position.
Figure 2. Lateral position.
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Excellence (NICE) (2005) suggests that sitting time should be
restricted to less than two hours per session. Sitting for long
periods of time can cause venous pooling, the development of
postural changes and contribute to pressure ulcer formation
(Collins, 2002). It is therefore important for the chair that the
person sits in to be suitable. Achieving a good sitting position
in an armchair depends on several factors:
n Correct seat height, depth and width
n Correct seat angle, armrest and back rest
n Appropriate upholstery
n Other accessories (Stewart, 2003),
In normal sitting the pelvis is positioned in a slight anterior
(forward) tilt and the body weight is taken evenly through both
ischial tuberosities.The hips are flexed to 90 degrees.The knees
and ankles are flexed to 90 degrees allowing us to place our feet
flat on the floor. A large portion of the body weight is shared
between both thighs (Collins, 1999, 2002). A chair that is too
low will not only be difficult to get out of but will also produce
pressure on the pelvis rather than distributing it evenly along
the thighs (Stewart, 2003). If the seat is too high the person’s
feet will not touch the floor and will cause pressure under the
thighs with the potential for swollen feet. If the person needs
a higher chair to enable them to stand up it is important to
provide a foot stool to support the feet (Broadbent, 2002).
Alternatively a better option might be to provide a seat riser
unit or even a riser/recliner chair which would enable the
person to alter their position independently (Rush, 2004). The
seat needs to be deep enough to support the full length of the
thighs and wide enough to enable the person to easily get into
the seat, but not so wide that it does not provide support or that
the person cannot reach the armrests (Stewart, 2003).
Patients who have hemiplegia following a stroke should
have their affected arm supported. The shoulder joint should
be correctly aligned and the weight of the arm supported
with an arm support or a pillow (Dowswell et al, 2000;
Goulding et al, 2004).
Patients who do spend substantial amounts of time in a
chair or wheelchair should be provided with a pressure-
redistributing device (EPUAP, 1998). It must be remembered
that a cushion placed on top of a seat will alter the chair’s
dimensions (Collins, 1999).
Positioning patients in wheelchairs
There are similar considerations when a person needs to
use a wheelchair for much of the time. It is important
to remember that a wheelchair must be matched to
the individual. Inappropriate wheelchair positioning can
contribute to a range of problems (See Box 1).
Pederson (2000) has described the ideal posture for
function:
n The pelvis is in a slight anterior pelvic tilt with no rotation
or slanting
n The spine should have the normal sitting curves
n The legs should be flexed near 90 degrees at the hip and
knee and in neutral (or 0 degrees) at the ankles. Slight
abduction (away from the midline) with neutral hip
rotation provides a stable base for support
n The head should be in midline allowing the eyes to look
forward.
British Journal of Nursing, 2007, Vol 16, No 5

Moving patients from supine to standing
Orthostatic hypotension is a fall in blood pressure when moving
to an upright position and quickly develops in bed- and chair-
bound patients causing faintness and dizziness (Pellatt, 2005).
This can be alleviated by gradually sitting a patient up in bed or
by ‘dangling’ where patients are assisted into the sitting position
with their legs hanging over the side of the bed before they are
moved into the standing position (Dingle, 2003).
Conclusion
Nurses have an important role to play in providing a bed that
has clean, unwrinkled bed linen, covers that are not too hot,
too heavy or too cold and enough supporting pillows. They
also have a major role in positioning patients so that they are
able to be as independent as possible and avoid the discomfort
and range of complications that are associated with poor
positioning. These are fundamental nursing skills that are
often considered routine but play a vital part in promoting
patient comfort and wellbeing. BJN
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Box 1. The consequences of poor
wheelchair positioning
Pressure ulcers
Skin tears
Skeletal deformities
Back and neck pain
Dysphagia
Impaired respiration and digestion
Contractures
Discomfort
Inability to self propel the wheelchair
Visual impairment
Incontinence
Social isolation
Unsafe transfers
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Gavin-Dreschnack (2005)
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CLINICAL SKILLS
Figure 3. Prone position.
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KEY POINTS
n Profiling beds provide comfort and safety for patients
and nurses.
n Bed making by nurses is more time efficient and safer for
patients if carried out in pairs.
n Poor positioning can cause a range of problems both
physical and psychosocial.
n Before moving and positioning a patient an ergonomic
risk assessment must be undertaken.
305
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