TURNING A CLIENT TO THE LATERAL POSITION IN
BED
Purpose
 This may be necessary when placing a bedpan
beneath the client, when changing the client’s
bed linen, or when repositioning the client.
For the Implementation
In the preparation we will assess for the ff:
1. Assistive devices that will be required.
2. Limitations to movement such as an IV or an
indwelling urinary catheter.
3. Medications the client is receiving because
certain medications may hamper movement or
alertness of the client.
4. Assistance required from other healthcare
personnel. Rationale: When lifting more than
35 pounds, caregivers should use assistive
devices to reduce injury risk.
In the performance
1. Prior to performing the procedure,
introduce self and verify the client’s
identity. Explain to the client what you
are going to do, why it is necessary, and
how to participate.
2. Perform hand hygiene.
3. Provide for client privacy.
4. Before the transfer, position yourself and
the client. Another person stands
opposite the bed.
 Adjust the head of the bed to a flat
position or as low as the client can
tolerate.
o Rationale: This provides
comfort for the client.
 Raise the bed to a height appropriate for
personnel safety.
 Move the client closer to the bedside
they will face when turned.
o Rationale: This ensures that the
client will be positioned safely in
the center of the bed after
turning.
 Pull the patient onto the bed using a
friction-reducing device. Then readjust
the client's legs and head.
 While standing next to the client, place the
client's arm over the chest. Abduct and
rotate the client's far shoulder.
o Rationale: Pulling the other arm
away from the body and externally
rotating the shoulder prevents it
from getting trapped.
 Place the client’s near ankle and foot
across the far ankle and foot.
o Rationale: This facilitates the
turning motion
 The individual on the client's side of the
bed should stand in line with their
waistline and as close to the bed as
possible.
5. Roll the client to a lateral position. The
other person will help us roll the client.
 Place one hand on the client's hip and
the other on their shoulder.
o Rationale: This supports the
client's two heaviest parts,
providing control during the
roll.
 Position and support the client's arms
and legs on their side.
TURNING A CLIENT TO THE PRONE POSITION
IN BED
To turn a client to the prone position, follow the
preceding steps, with two exceptions.
 Instead of abducting the client's arm, keep
it alongside the body for rolling.
o Rationale: This minimizes
trapping when rolling.
 Roll the client completely onto the
abdomen.
o Rationale: It's important to bring
the client as close to the bed's edge
as possible so they can roll to the
center.
 Never pull a client across the bed while the
client is in a prone position.
 o Rationale: This can injure a woman’s
breast or a man’s genitalia.
6. Document all relevant information,
record the ff:
 Time
 Previous position and position after
turning
 Signs of pressure areas
 Use of support devices
 Ability of client to assist in moving and
turning
 Response of the client to moving and
turning such as anxiety, discomfort, or
dizziness
ASSISTING A CLIENT TO SIT ON THE SIDE OF THE
BED (DANGLING)
The purpose of this is:
 For the client to assume a sitting position on the
edge of the bed before walking, moving to a
chair, eating, or doing other activities.
Implementation
In the preparation, assess the:
1. Assistive devices that will be used
2. Movement limitations, such as an IV or urine
catheter
3. Medications the client is taking, as some can
impair movement or alertness.
4. Assistance required from other healthcare
personnel.
Performance:
1. Prior to performing the procedure,
introduce yourself and verify the client’s
identity. Explain to the client what you
are going to do, why it is necessary, and
how to participate
2. Perform hand hygiene
3. Provide client privacy
4. Before performing a transfer, position
yourself and the client properly.
 Assist the client to a lateral position facing
you using an assistive device.
 Raise the bed head slowly to its highest
position.
o Rationale: This reduces the gap a
client must go to sit up in bed.
 Position client's feet and lower legs at
bed's edge.
○ Rationale: This allows the client's
feet to move easily off the bed, and
gravity helps them sit up.
 Face the bed's corner from the client's hips
(the angle in which movement will occur).
 Assume a broad stance with the foot
nearest the client and bed head forward.
Lean from the hips. Flex hips, knees, and
ankles.
5. Move the client to a sitting position,
using an assistive device.
 Place one arm under the client's shoulders
and the other arm around both thighs at
the knees.
○ Rationale: Shoulder support
avoids backsliding. Supporting a
client's thighs reduces friction and
improves movement force.
 Tighten your glutes, abdominal, leg, and
arm muscles.
 Pivot on the balls of your feet in the
desired direction facing the foot of the bed
while pulling the client’s feet and legs off
the bed.
○ Rationale: Spine twisting is
prevented by pivoting. The client's
legs swinging downward increase
lower body movement and help
verticalize the upper body.
 Keep supporting the client until the client
is well balanced and comfortable.
○ Rationale: This movement may
cause some clients to become light-
headed or dizzy.
 Assess vital signs.
6. Document all relevant information.
Record the ff:
 Ability of the client to assist in moving
and turning
  Type of assistive device, if one was used
 Response of the client to moving and
turning (dizziness and discomfort)
For the evaluation:
 Check the pressure areas' skin integrity. If
available, compare results to previous
evaluations.
 Assess old and new skin lesions.
 After moving, check alignment. Assess the
client's appearance and comfort.
 Check for safety measures such as the side
rails.
 Determine the client's tolerance such as the
vital signs before and after dangling.
 Report changes to the PCP.
TRANSFERRING BETWEEN BED AND CHAIR
The purpose of this is:
 A client may need to be transferred between
the bed and a wheelchair or chair, the bed
and the commode, and the toilet.
For the assessment, before transferring the
client we will assess for:
1. The client’s body size and weight
2. Ability to follow instructions
3. Ability to bear weight (full, partial, or none)
4. Ability to position and reposition feet on
floor
5. Ability to push down with arms and lean
forward
6. Ability to grasp
7. Ability to achieve independent balance
8. Activity tolerance
9. Muscle strength and joint mobility
10. Presence of paralysis and orthostatic
hypotension
11. Level of comfort
12. The technique with which the client is
familiar
13. The transfer space (bathrooms, for example,
are usually cramped)
14. Number of assistance needed for a safe
transfer.
Then, the equipment we will be needing are:
 Robe or appropriate clothing
 Slippers or shoes with nonskid soles
 Gait/transfer belt
 Chair, commode, wheelchair as
appropriate to client need
 Slide board and lift, if appropriate
IMPLEMENTATION
For the preparation:
 Plan what to do and how to do it.
 Obtain essential equipment before starting
and check that all equipment is functioning
correctly.
 Remove obstacles from the area so clients
do not trip.
Performance:
1. Prior to performing the procedure,
introduce yourself and verify the
client’s identity. Explain to the client
what you are going to do, why it is
necessary, and how to participate
2. Perform hand hygiene
3. Provide client privacy
4. Arrange equipment properly
 Lower the bed so the client's feet touch the
floor. Lock the bed's wheels
 Place the wheelchair parallel to and near
the bed. Put the wheelchair on the client's
stronger side of the bed. Lock the wheels,
raise the footplates, and remove the leg
rests.
5. Prepare and assess the client.
 Assist the client to a sitting position on the
side of the bed.
 Assess the client for orthostatic
hypotension.
 Assist the client in putting on a bathrobe
and nonskid slippers.
 Place a transfer belt snugly around the
client’s waist. Check that the belt is
securely fastened.
6. Give explicit instructions to the client.
Ask the client to:
 Move forward and sit on the edge of the
bed with feet flat on the floor.
o Rationale: This brings the client’s
center of gravity closer to the
nurse’s.
 Lean forward slightly from the hips.
o Rationale: This aligns the client's
head and trunk in the direction of
movement and brings their center of
gravity closer to the base of support.
 Place the foot of the stronger leg beneath the
edge of the bed and put the other foot
forward.
o Rationale: In this way, the client can
stand and move using stronger leg
muscles. A wider support base helps
the client during the transfer.
 Place the client’s hands on the bed surface so
that the client can push while standing.
o Rationale: This increases the
movement's force and decreases
back strain risk.
 The client should not grasp your neck for
support.
o Rationale: This can injure the nurse.
7. Position yourself correctly.
 Stand in front of the client and to their side.
 Hold the gait or transfer belt with one hand
and the client's shoulder with the other. Lean
from the hips. Flex hips, knees, and ankles.
 Assume a broad stance, with one foot
forward and one back. Support the client's
feet to avoid sliding forward or laterally.
 If feasible, mirror the client's feet.
○ Rationale: This prevents loss of
balance during the transfer
8. Assist the client to stand, and then move
together toward the wheelchair to which
to transfer the client.
 On the count of three or the verbal
instructions “Ready– steady–stand,” ask the
client to push against the mattress/side of
the bed while you transfer your weight from
one foot to the other (while keeping your
back straight) and stand upright moving the
client forward (toward your center of
gravity).
 If the patient needs more than a tiny amount
of pulling, a mechanical device should be
employed.
 Support the client in an upright standing
position for a few moments.
o Rationale: This allows the nurse and
client to extend the joints and
ensures the client's stability before
leaving the bed.
 Together, pivot on the foot farthest from
the chair or move toward the wheelchair,
bed, chair, commode, or car seat.
9. Assist the client to sit.
 Move the wheelchair forward or have the
client back up to it and place their legs on
the seat.
o Rationale: Having the client rest
their legs on the wheelchair seat
reduces the risk of falling.
 Make sure the wheelchair brakes are on.
 Have the client touch the wheelchair's
arms.
 Stand directly in front of the client. Place
one foot forward and one back
 Tighten the gait belt and our gluteal,
abdominal, leg, and arm muscles.
 While bending your knees and hips, lower
the client into the wheelchair seat.
10. Ensure client safety.
 Ask the client to push back into the
wheelchair seat.
o Rationale: Sitting back on the seat
provides stability and reduces the
risk of falling off the wheelchair. A
wheelchair or bedside commode
can slip forward if the client leans
far forward.
 Remove the gait or transfer belt.
 Lower the leg rests and footplates, and
place the client’s feet on them, if
applicable.
11. Document relevant information:
 Client’s ability to bear weight and pivot.
 Number of transfer staff and safety
measures used.
 Length of time up in chair.
 Client response to transfer and being up in
a chair or wheelchair.
ASSISTING A CLIENT TO AMBULATE
The purpose of this is:
 To provide a safe condition for the client to
walk with whatever support is needed
For the assessment, assess the ff:
 1. Length of time in bed and the amount and
type of activity the client was last able to
tolerate
2. Vital signs
3. ROM of joints needed for ambulating
4. Muscle strength of lower extremities
5. Need for ambulation aids
6. Medications that cause dizziness and
orthostatic hypotension.
7. Presence of joint inflammation, fractures,
and muscle weakness.
8. Ability to understand directions.
9. Level of comfort.
The equipment we will be needing are:
 Assistive devices required for safe
ambulation of client.
 Wheelchair to accompany client or chairs
along path for resting.
 Portable oxygen tank if the client needs it.
IMPLEMENTATION
For the preparation:
Ensure you have help available. And plan a safe
route for ambulation.
For the performance:
1. Prior to performing the procedure,
introduce self and verify the client’s
identity using agency protocol. Explain to
the client how you are going to assist, why
ambulation is necessary, and how to
participate. Discuss how this activity
relates to the overall plan of care.
2. Perform hand hygiene and observe
appropriate infection prevention
procedures.
3. Ensure that the client is appropriately
dressed to walk and has shoes or slippers
with nonskid soles.
4. Prepare the client for ambulation.
 Have the client sit up in bed for at least 1
minute prior to preparing to dangle legs.
 Assist the client to sit on the edge of the bed
and allow dangling for at least 1 minute.
 Before leaving the bedside, check for
orthostatic hypotension.
o Rationale: Allowing gradual
adjustment helps minimize blood
pressure decreases and fainting from
lying to sitting and sitting to
standing.
 Assist the client to stand by the side of the
bed for at least 1 minute until she feels
secure.
 Assess IV tubing, catheters, and drainage
bags. Keep bags below the client's bladder.
○ Rationale: To prevent backflow of
urine into bladder and risk of
infection.
 If the client is medically unstable,
inexperienced with assistive devices, or
has neurological problems, use a lift with
an ambulation sling and 1 to 2 caregivers.
 If the client is a high safety risk, has
upper extremity strength, and can grasp
with one hand, use a lift with an
ambulation sling and 1 to 2 caregivers.
 If the client is a low safety risk use a gait
or transfer belt for standby assist as
needed and 1 to 2 caregivers. Make sure
the client's belt is snug and fastened. Grab
the client's belt and step behind and to one
side.
5. Ensure client safety while assisting the
client to ambulate.
 Encourage the client to ambulate
independently, but walk by her weak side
if necessary.
o If the client has a lightweight IV
pole for infusing fluids, holding
onto it may aid with balance.
o If the pole or other equipment is
heavy, the nurse must push it to
match the client's speed, getting
assistance as needed.
 Remain physically close to the client in
case assistance is needed at any point.
 If it's the client's first time out of bed after
surgery, injury, or an extended period of
immobility, or if they're weak or unstable,
have assistance follow you with a
wheelchair in case it's needed.
 Encourage the client to walk normally. Ask
the client to straighten his back and raise
his head so his eyes are gazing in a normal
horizontal plane.
o Rationale: Uncertain clients who
stare at their feet are more likely to
fall.
 6. Protect the client who begins to fall while
ambulating.
 If a client shows signs of orthostatic
hypotension or acute weakness, get her into
a wheelchair and help the client to lower the
head between the knees.

 Stay with the client.

o Rationale: A client who faints while
in this position could fall head first
out of the chair.
 When the weakness subsides, assist the
client back to bed.
 Never catch a falling client. A caregiver is
unlikely to prevent a client from falling.
 Quickly remove obstacles out of the way that
may injure the client.
 Do not manually lift a client from the floor;
use SPHM technology.

Lastly for the Evaluation:

Establish a plan for continued ambulation based on
the client's expected or normal capabilities.