PREPARATIONS

1. Introduce self and verify client’s identity using agency protocol. Explain to the To establish rapport and cooperation
client what you are going to do, why it is necessary, and how he or she can
participate
2. Assess client’s physiological motor and cognitive status. Determine if To determine what kind of assistance
assistance would be needed from other health care personnel. is required to avoid injuries
3. Prepare all necessary equipment and supplies for the procedure. To save time and effort
4. Perform hand hygiene and observe other appropriate infection prevention To deter the spread of microorganism
procedures.
5. Provide privacy. Screen the patient’s bed, close the door To maintain the patient dignity
6. Adjust the bed and the client’s position. To prevent any possible injuries
a. Adjust the head of the bed to a flat position or as low as the client can
tolerate.
b. Raise the bed to a height appropriate for personnel safety.
c. Lock the wheels on the bed and raise the opposite side rail.
d. Remove all pillows, then place one against the head of the bed
7. Secure all of client’s attachments. To prevent accidents
8. Lower the siderails of the bed. To prepare for the transfer
MOVING THE CLIENT UP IN THE BED (TWO PERSON)
9. Ensure client is in a supine position. For better repositioning
10. Place a draw sheet or friction-reducing slide sheet under the client’s back. To minimize friction and reducing skin
injuries
11. Face the head of the bed. Both of the nurses standing at the different sides Proper body mechanics prevents
of the bed with feet placed apart. injuries
12. Place the client’s arms across the chest. Ask the client to flex the neck during To prevent injuries and to prepare for
the move and keep the head off the bed surface. If possible, ask the patient to the moving the patient
bent his knees, bringing his feet close to his buttocks as possible.
13. Roll the draw sheet of the friction-reducing slide sheet and flex your knees To allow the patient to be moved
and hips, bringing the forearm closer to the level of the bed. carefully
14. Inform the client that he will be moved up in the bed on the count of three To allow the patient what to expect and
as nurses will lift the draw sheet or the friction-reducing slide sheet. gain cooperation
15. Move in coordination to transfer the client up towards the head of the bed. To lower the risk of injuries for the
patient and HCP
16. Reassess client’s body alignment and ensure comfort. To ensure the patient comfort and
position
17. Raise the siderails of the bed. Place the call bell within client’s reach. To maintain patient safety
LOGROLLING THE CLIENT (TWO PERSON)
18. Perform the necessary procedures that would prepare the client for the To save time and effort.
transfer.
19. Position the client in a supine position. For better repositioning
20. Place a draw sheet or friction-reducing slide sheet under the client’s back To minimize friction and reducing skin
and hips. injuries
21. Pull the client to the side of the bed. Proper body mechanics prevents
a. Stand with another nurse on the same side of the bed. Assume a broad stance injuries
with one foot forward, roll and grasp the edge of the draw sheet or the friction-
reducing device.
b. On a signal, pull the client toward both of you. Both of the nurses pull the
client to the side of the bed by shifting their weight to the back foot.
22. One nurse moves to the side of the bed, and places supportive devices for To prevent any possible injuries
the client when turned, one pillow at the head part and another pillow between
the client’s legs.
23. Cross the client’s arm over his chest. This prevents excessive movement of the
arms
24. Roll and position the client in proper alignment. This ensures a smooth and controlled
a. Fanfold or roll the draw sheet/friction-reducing device alongside of the client. transferring to reduce injuries
One nurse goes to the other side of the bed away from the rolled draw
sheet/friction reducing device. The nurse assumes a stable stance and reaching
over the client, grasp the draw sheet/friction reducing device at the shoulder
part of the client and hips.
b. The second nurse (behind the client) helps turn the client and provides pillow
supports to ensure good alignment in the lateral position.
c. On a signal, both of the nurses roll the client as one unit in a smooth,
continuous motion.
25. Support the client’s head, back, and upper and lower extremities with To ensure the patient safety and
pillows. Ensure proper alignment of client’s body and comfort comfort
26. Raise the side rails and place the call bell within the client’s reach. To reduce the risk for falls and injuries
ASSISTING A CLIENT TO SIT ON THE SIDE OF THE BED
27. Perform the necessary procedures that would prepare the client for the To save time and effort
transfer.
28. Position yourself and the client appropriately before performing the move. Proper body mechanics prevents
a. Assist the client to a lateral position facing you, using an assistive device injuries
depending on client’s assistance needs.
b. Raise the head of the bed slowly to its highest position.
c. Position the client’s feet and lower legs at the end of the bed.
d. Stand beside the client’s hips and face the far corner of the bottom of the bed
(the angel in which movement will occur). Assume a broad stance, placing the
foot nearest the client and head of the bed forward. Lean your trunk
forwards from the hips. Flex your hips, knees, and ankles.
29. Move the client to a sitting position, using an assistive device depending on To helps maintain their stability and
client assistance needs. prevent them from sliding or falling during
a. Place the arm nearest to the head of the bed under the client’s shoulders and the transfer.
the other arm over both of the client’s thighs near the knees.
b. 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 of the bed.
c. Keep supporting the client until the client is well balanced and comfortable.
Place the call bell within the client’s reach.
TRANSFERRING BETWEEN BED AND CHAIR
30. Perform the necessary procedures that would prepare the client for the To save time and effort
transfer
31. Position the equipment appropriately. To prevent any possible injuries or
a. Lower the bed to its lowest position so that the client’s feet will rest flat on accidents
the floor. Lock the wheels of the bed.
b. Place the wheelchair/chair parallel to the bed and as close to the bed as
possible, facing the foot of the bed. Position the wheelchair/chair that would
allow the client to move forward his or her stronger side, if using wheelchair.
Lock the wheels of the wheelchair and raise the footplate

32. Assist the client to a sitting position on the side of the bed. For easier transfer

33. Assess the client for orthostatic hypotension before moving the client from To prevent fainting or falls when the
the bed. patient changes from a lying to a standing
position.
34. Assist the client in putting on a bathrobe and nonskid slippers or shoes. If To prevent the patient from falling or
available, place a gait/transfer bell snugly around the client’s waist. Check to be slipping
certain that the belt is securely fastened.
35. Give explicit instructions to the client. Ask or position the client to: Providing clear instructions to the patient
a. Move forward and sit on the edge of the bed (or surface on which the client’s helps them to cooperate during the
sitting) with feet placed flat on the floor. transition.
b. Lean forward slightly from the hips.
c. Place the foot of the stronger leg beneath the edge of the bed (or sitting
surface) and put the other foot forward.
d. Place the client’s hands on the bed surface (or available stable area) so that
the client can push while standing.
36. Position yourself correctly Proper body mechanics prevents
a. Stand directly in front of the client and to the side requiring the most support. injuries
Hold the gait/transfer belt with the nearest hand; the other hand supports the
back of the client’s shoulder.
b. Assume a broad instance, placing one foot forward and one back. Brace the
client’s feet with your feet to prevent the client from sliding forward or laterally.
Mirror the placement of the client’s feet, if possible.
37. Assist the client to stand, and then move together by pivoting toward the To ensure a controlled and safe transfer
wheelchair or sitting area to which you wish to transfer the client.
38. Assist the client to sit in the wheelchair or chair maintaining proper posture To prevent discomfort
of the client.
39. Ensure client’s safety and comfort. To reduce risk of falls and injuries.
TRANSFERRING BETWEEN BED AND STRETCHER
40. Perform the necessary procedures that would prepare the client for the To save time and effort
transfer.
41. Adjust the client’s bed in preparation for the transfer. Ensure bed wheels are To ensure the bed will not move and
locked. cause injuries
42. Place a draw sheet or friction-reducing slide sheet under the client’s back To minimize friction and prevent skin
and hips. injuries
43. Place the stretcher parallel to the bed next to the client and lock the To ensure stable platform
stretcher wheels. You may fill the gap that exists between the bed and the
stretcher loosely with the bath blankets.
44. Transfer the client securely to the stretcher. Proper body mechanics and
a. One nurse needs to be at the side of the client’s bed, between the client’s transferring can prevent injuries and
shoulder and hip. accidents
b. The second nurse should be at the side of the stretcher positioned between
the client’s shoulder and hip.
c. The nurse must position their feet in walking distance.
d. Cross the client’s arm over his chest. Ask the client to flex the neck during the
move, if possible.
e. On a planned command, the nurse at the stretcher’s side pull (shifting weight
to the rear foot), and the nurse at the bedside pushes the client toward the
stretcher (shifting weight to the front foot).
45. Ensure client comfort and safety. To reduce risk of falls and injuries.
TRANSFERRING BETWEEN BED AND STRETCHER (TWO PERSON)
46. Do aftercare. Secure assistive devices. If used. Securing assistive devices maintains their
stability and minimizes the risk of injury
47. Perform proper handwashing. To deter the spread of microorganism
48. Document all relevant information. Record: time and change of position For continuity of care and effective
moved from and position moved to, any signs of pressure areas, use of support communication among healthcare
devices, ability of client in moving and bearing weight and response of the client providers
to moving and turning (e.g., anxiety, discomfort, dizziness).
49. Reports the nurse-on-duty or attending physician for any pertinent For timely assessment and intervention if
observation. necessary