Attachment A:

HAND HYGIENE
Related Course(s) Microbiology, Health Promotion and Maintenance
Theoretical content Hand Hygiene
Asepsis
Definition Hand hygiene is the act of cleaning one's hands with the use of soap and water, or
with the use of another liquid (hand sanitizer) for the purpose of removing soil,
dirt, and/or microorganisms. It is a general term referring to any action of hand
cleansing and it includes:
• Washing hands with the use of water and soap or a soap solution, either
non antimicrobial or antimicrobial.
• Applying a waterless antimicrobial hand rub to the surface of the hands
(e.g., alcohol-based hand rubs).
• When performed correctly, hand hygiene results in a reduction of
microorganisms on hands.
Rationale  To reduce the number of microorganisms on the hand.
 To reduce the risk of transmission of microorganism to clients.
 To reduce the risk of cross contamination among clients.
 To reduce the risk of transmission of infectious organism to oneself
Principles  Transient bacteria are removed by thorough washing with soap and water.
 Microorganisms live everywhere in the environment but can become
pathogenic when they are removed from their normal place of habitat.
 Healthy skin is relatively dry, therefore a macerated skin resulting from
excessive moisture and dryness, results in cracking, and decreases the
skin’s resistance to pressure and infection.
 Soap reduces surface tension of water and contacting surfaces. It is
however an irritant certain delicate tissue and makes the skin dry if left on.
 Most bacteria prefer a neutral or slightly alkaline environment, therefore
the skin secretion which has a pH of 5.5 are bacteriostatic.
 When the integrity of the skin is broken, routes of entry are opened for
pathogenic microorganisms.
 Effective Hand Hygiene is the single most important strategy in preventing
health care associated infections.
 Hand hygiene practices have been universally poor among health care
workers.
 An alcohol-based hand rub should be uses for all clinical situations where
hands are visibly clean.
 Hands should be washed with soap and water when visibly dirty or
contaminated with proteinaceous material, or visibly soiled with blood or
other body fluids, or if exposure to potential spore forming organisms is
strongly suspected or proven, or after using the bathroom.
 Nail polish must not be worn by healthcare professionals providing direct
patient care. Chipped nail polish supports the growth of large numbers of
organisms on the fingernails.
 Artificial nails must not be worn by healthcare professionals providing
direct patient care. A growing body of evidence suggests that wearing
artificial nails may contribute to the transmission of certain healthcare
associated microorganisms.
 Natural nail tips must be less than 0.6 centimeters (1/4 inch) long.
Whether the length of the nail is a substantial risk is unknown. However,
long sharp fingernails can puncture gloves.
 Nail art and technology must not be worn. There is limited information

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 about nail art but they may be a potential reservoir of microorganisms.
 Residual moisture left on the hands may harbor bacteria.
 After cleansing hands, they must be dried before touching a patient or
commencing a procedure.
• The "Five Moments" for washing hands should be followed (Figure 1):
 Before patient care
 Before an aseptic task
 After environmental contact
 After exposure to blood/body fluids
 After patient care

Figure 1 - The "Five Moments" for washing hands

Font: WHO (2009). Available at:
[Link]
Requisities 1. For hand hygiene with soap and water:
• Running water
• Liquid or bar soap
• Paper towels or hot air dryer

2. For hand hygiene with alcohol-based hand rub:

• Alcohol-based hand rub with a concentration of at least 70%
• Alcohol-based hand rub dispenser
Procedures:
Hand hygiene with soap and water: (Duration: 40-60 seconds)
1. Gather the necessary supplies;
2. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing
procedure;
3. Remove jewelry;
4. Wet hands with water;
5. Apply enough soap to cover all hand surfaces;
6. Rub hands palm to palm;
7. Right palm over left dorsum with interlaced fingers and vice versa;
8. Palm to palm with fingers interlaced;
9. Backs of fingers to opposing palms with fingers interlocked;
10. Rotational rubbing of left thumb clasped in right palm and vice versa;
11. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and
vice versa;
12. Rinse hands with water;

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 13. Dry hands thoroughly with a single use towel;
14. Use towel to turn off faucet;
15. Your hands are now safe.

Figure 1 – Performing hand hygiene using soap and water (handwashing)

Font: WHO (2009)

Hand hygiene with alcohol-based hand rub: (Duration: 20-30 seconds)

16. Apply a palmful of the product in a cupped hand, covering all surfaces;
17. Rub hands palm to palm;
18. Right palm over left dorsum with interlaced fingers and vice versa;
19. Palm to palm with fingers interlaced;
20. Backs of fingers to opposing palms with fingers interlocked;
21. Rotational rubbing of left thumb clasped in right palm and vice versa;
22. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and
vice versa;
23. Once dry, your hands are safe.

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 Figure 2 – Performing hand hygiene with alcohol-based hand rub
Font: WHO (2009)
Nursing Documentation
Not applicable.
References
1. World Health Organization. WHO guidelines on hand hygiene in healthcare: 2009. Available:
[Link] Accessed at: 22
May, 2023.
2. World Health Organization. Core competencies for infection prevention and control professionals.
Genève: WHO; 2020. p. 69.
3. 3. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis:
Elsevier; 2021.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023

4/2
 Attachment B:
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Related Course(s) Microbiology
Theoretical content Personal Protective Equipment (PPE)
Definition PPE is defined as “specialized clothing or equipment, worn by an employee for
protection against infectious materials.
Rationale  To protect health care personnel from exposure to or contact with
infectious agents. These include gloves, face masks, protective eyewear,
face shields, and protective clothing (e.g., reusable or disposable gown,
jacket, lab coat).
 To prevent microorganisms from spreading from health care personnel to
patients.
Principles  The protection of healthcare personnel from infectious disease exposures
in the workplace requires a combination of controls, one of which is the
use of PPE.
 It is important to recognize that healthcare worker protection also
involves other prevention strategies.
 There are four major components to healthcare worker safety programs:
training; engineering controls like negative pressure rooms for patients
with airborne diseases such as TB; work practice controls such as not
recapping needles; and personal protective equipment.
 While PPE is last in the hierarchy of prevention, it is very important for
protecting healthcare workers from disease transmission.
 Health care personnel should wear a surgical mask that covers both their
nose and mouth during procedures that are likely to generate splashes or
sprays of blood or body fluids and while manually cleaning instruments. A
surgical mask also protects the patient from microorganisms generated by
the wearer. When a surgical mask is used, it should be changed between
patients or during patient treatment if it becomes wet.
 Health care personnel should wear protective eyewear with solid side
shields or a face shield during procedures likely to generate splashes or
sprays of blood or body fluids or the spatter of debris. Reusable protective
eyewear should be cleaned with soap and water, and when visibly soiled,
disinfected between patients.
 Health care personnel should wear gowns to prevent contamination of
street clothing and to protect the skin from exposure to blood and body
fluids. Sleeves should be long enough to protect the forearms. Protective
clothing should be changed when it becomes visibly soiled by blood or
other body fluids. Health care personnel should remove protective
clothing before leaving the work area.
 Health care personnel wear gloves to prevent contamination of their
hands when touching mucous membranes, blood, saliva, or other
potentially infectious materials and to reduce the likelihood that
microorganisms on their hands will be transmitted to patients during
patient care. Gloves should be used for one patient only and discarded
appropriately after use. Gloves should not be washed for reuse. Always
perform hand hygiene immediately after glove removal. Glove users
should consult the glove manufacturer about the compatibility of glove
material with various chemicals.
 The procedure for putting on and removing PPE should be tailored to the
specific type of PPE.
 The sequence for putting on personal protective equipment (PPE) is:
1 – Gown
 2 – Mask of respirator
3 – Goggles or face shield
4 - Gloves

1 – GOWN 2 – MASK OR RESPIRATOR

3 – GOGGLES OR FACE SHIELD 4 – GLOVES

Figure 1 - The sequence for putting on personal protective equipment (PPE)

Font: CDC (n.d.). Available at: [Link]
[Link]
Requisities  Soap and water or alcohol-based sanitizer for hand washing
 Paper towels
 PPE for a specified purpose
 Trash can with lid and pedal for disposal of used PPE
Procedures
1. Wash your hands with soap and water or an alcohol-based hand sanitizer before touching PPE;
2. Follow the sequence:

Gown:
3. Check if the gown is clean and intact. If it is disposable, check the expiration date and if there are
any defects, such as tears or holes;
4. Pick up a clean gown, and allow it to unfold in front of you without allowing it to touch any area
soiled with body substances;
5. Put on the gown by passing your arms through the sleeves and letting it fall onto your body;
6. Tie the gown's ties or fasteners at the back of the neck and waist, making sure it is well adjusted
and covering your entire torso, from the neck to the knees, and the sleeves to the wrists;

Figure 1 – Putting on the gown

Font: CDC (n.d). Available at: [Link]

Mask or respirator:
7. Check if the mask has any tears or holes;
8. Identify which side is the top (usually where the metal strip is);
 9. Place the mask over your face, covering your nose, mouth, and chin, and make sure it is fitted
correctly around the nose and chin;
10. Secure the mask behind your ears or at the back of your head (depending on the type of mask);
11. Adjust the metal strip on the top of the mask so it fits comfortably around your nose;
12. Make sure the mask is tightly fitted to your face, avoiding any gaps between your face and the
mask;
13. Avoid touching the mask while wearing it. If you need to touch the mask, wash your hands with
soap and water or an alcohol-based hand sanitizer immediately before and after touching the
mask;

Figure 2 – Putting on the mask or respirator

Font: CDC (n.d). Available at: [Link]

Observation:
 Remind users not to touch their mouth or nose, which could otherwise transfer viruses and
bacteria after touching a contaminated surface.
 Masks also reduce the spread of infectious liquid droplet carrying bacteria or viruses that are
created when the user coughs and sneezes or protect them from inhaling airborne bacteria or
virus particles
 The following types of masks are available:
 Surgical masks: typically used by healthcare professionals during surgical procedures to
protect the patient from bacteria present in the healthcare worker's mouth and nose.
 N95 masks: recommended for healthcare professionals who deal with infectious disease
patients, as they offer greater protection against smaller particles, such as viruses and
bacteria.
 Cloth masks: recommended for general use in communities and public spaces, as they may
help reduce the spread of respiratory droplets, but do not offer the same level of protection
as surgical or N95 masks.

Goggles or Face Shield:

14. Place goggles (or face shield) over your face, positioning the lenses in front of your eyes;
15. Adjust the temples of the safety glasses so they are comfortable and secure. The temples should
rest firmly behind the ears, without being too tight or causing discomfort;
16. Check to ensure that the safety glasses fit properly on your face and fully cover your eyes. There
should be no gaps between the safety glasses and your face;

Figure 3 – Putting on goggles or face shield

Font: CDC (n.d.). Available at: [Link]
Gloves:
 Disposable gloves (non-sterile gloves):
17. Open the glove box and select the appropriate size;
18. Carefully pick up one glove by the cuff and place it on one hand;
19. With the gloved hand, pick up the other glove and place it on the other hand;
20. Ensure that the gloves are properly fitted and completely cover the hands;
21. With the gloved hand, grasp the edge of the opposite glove at the wrist;
22. Pull the glove down toward the fingers until it comes off completely and is inverted;
23. Holding the inverted glove, place the other hand under the glove at the edge opposite the wrist;
24. Pull the glove down, inverting it, until it comes off completely and is inside the other glove;
25. Dispose of the used gloves in an appropriate container;

Figure 4 - Doffing non-sterile gloves

Font: WHO (2009)

 Sterile gloves:
1. Open the sterile glove package carefully, avoiding touching the sterile part of the package;
2. Carefully pick up one glove by the cuff and place it on one hand, being careful not to touch
anything non-sterile;
3. With the gloved hand, pick up the other glove and place it on the other hand, being careful not to
touch anything non-sterile;
4. Ensure that the gloves are properly fitted and completely cover the hands;
5. With the gloved hand, grasp the edge of the opposite glove at the wrist;
6. Pull the glove down toward the fingers until it comes off completely and is inverted;
7. Holding the inverted glove, place the other hand under the glove at the edge opposite the wrist;
8. Pull the glove down, inverting it, until it comes off completely and is inside the other glove;
9. Hold the two inverted gloves and dispose of them in an appropriate container without touching
anything non-sterile.
 Figure 5 - Doffing sterile gloves
Font: WHO (2009)

Observations:
 Most patient care activities require the use of a single pair of nonsterile gloves made of either
latex, nitrile, or vinyl.
 Because of allergy concerns, some facilities have eliminated or limited latex products, including
gloves, and now use gloves made of nitrile or other material.
 Vinyl gloves are also frequently available and work well if there is limited patient contact.
However, some gloves do not provide a snug fit on the hand, especially around the wrist, and
therefore should not be used if extensive contact is likely.
 Gloves should fit the user’s hands comfortably – they should not be too loose or too tight. They
also should not tear or damage easily.
 Gloves are sometimes worn for several hours and need to stand up to the task.
 Sterile surgical gloves are worn by surgeons and other healthcare personnel who perform invasive
patient procedures. During some surgical procedures, two pair of gloves may be worn.
 Environmental services personnel often wear reusable heavy-duty gloves made of latex or nitrile
to work with caustic disinfectants when cleaning environmental surfaces. However, they
sometimes use patient care gloves too.
 Gloves protect healthcare professional against contact with infectious materials.
 Once contaminated, gloves can become a means for spreading infectious materials to the
healthcare professional, other patients or environmental surfaces.
 The way the healthcare professional use gloves can influence the risk of disease transmission in
healthcare settings
 The following types of gloves are available:
 Disposable gloves: are different types of disposable gloves, including latex, vinyl, and nitrile
gloves.
 Sterile gloves: sterile gloves may be necessary for invasive and surgical procedures where a
sterile barrier is required.
Removing PPE:
1. Remove all PPE before exiting the patient room except a respirator, if worn;
2. Remove the respirator after leaving the patient room and closing the door;
3. Remove PPE in the following sequence:

Gloves:
 Removing non-sterile gloves:
4. Outside of gloves are contaminated!
5. If your hands get contaminated during glove removal, immediately wash your hands or use an
alcohol-based hand sanitizer;
6. Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove;
7. Hold removed glove in gloved hand;
8. Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first
glove;
9. Discard gloves in a waste container;

Figure 6 - Removing non-sterile gloves

Font: WHO (2009)
Goggles or Face Shield:
10. Outside of goggles or face shield are contaminated!
11. If your hands get contaminated during goggle or face shield removal, immediately wash your
hands or use an alcohol-based hand sanitizer;
12. Remove goggles or face shield from the back by lifting head band or ear pieces;
13. If the item is reusable, place in designated receptacle for reprocessing; otherwise, discard in a
waste container;

Figure 7 - Removing the goggles or face shield

Font: CDC (n.d.). Available at: [Link]

Gown:
14. Gown front and sleeves are contaminated!
15. If your hands get contaminated during gown removal, immediately wash your hands or use an
alcohol-based hand sanitizer;
16. Unfasten gown ties, taking care that sleeves don’t contact your body when reaching for ties;
17. Pull gown away from neck and shoulders, touching inside of gown only;
18. Turn gown inside out;
19. Fold or roll into a bundle and discard in a waste container;
 Figure 8 - Removing the gown
Font: CDC (n.d.). Available at: [Link]

Mask or respirator:
20. Front of mask/respirator is contaminated — DO NOT TOUCH!
21. If your hands get contaminated during mask/respirator removal, immediately wash your hands or
use an alcohol-based hand sanitizer;
22. Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove
without touching the front;
23. Discard in a waste container;

Figure 9 – Removing the mask or respirator

Font: Font: CDC (n.d.). Available at: [Link]

24. Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE.

Figure 10 – Washing hands with water and soup or hand hygiene with alcohol-based hand rub
Font: Font: CDC (n.d.). Available at: [Link]

Observation: It is important to remember that the mask should be replaced with a new one if it becomes
damp, dirty, or damaged, and that hands should be washed frequently regardless of mask use.
Nursing documentation
Not applicable
References
1. Centers for Disease Control and Prevention (n.d.). Sequence for putting on personal protective
equipment (PPE). Available at: [Link] Access at:
22 May, 2023.
2. Centers for Disease Control and Prevention (2020). Personal Protective Equipment. Available at:
[Link]
[Link]#:~:text=PPE%20are%20special%20coverings%20designed,%2C%20jacket%2C
%20lab%20coat. Access at: 22 May, 2023.
3. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis: Elsevier;
2021.
4. World Health Organization. Advice on the use of masks in the context of COVID-19. Genève:
WHO; 2020. p. 5.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment C:
PATIENT UNIT CLEANING AND DISINFECTION
Related Course(s) Microbiology
Theoretical content Asepsis
Definition Practices involving environmental cleaning procedures in patient care areas to
reduce the probability of contamination, the vulnerability of the patients to
infection, and the potential for exposure (i.e., high-touch vs low-touch surfaces).
The determination of environmental cleaning procedures for individual patient
care areas, including frequency, method, and process, should be based on the risk
of pathogen transmission.
Rationale  To prepare the patient unit in a manner that ensures a safe, comfortable,
and organized environment, free from dirt and contamination, thereby
preventing microbial spread. There are two types:
 Routine Cleaning: should be carried out at least daily.
 Terminal Cleaning: should be carried out after hospital discharge, or when
the patient stays in the hospital for an extended period, as well as in
situations of death, transfer, and isolation termination.
Requisities 1. Cleaning and disinfection with neutral detergent and water or
Polyhexamethylene Biguanide (PHMB):
 Hamper
 Neutral detergent and water or PHMB solution bottle, a standardized
product in the institution - follow the manufacturer's dilution instructions
 Disposable cleaning cloths
 Paper towels
 2 pairs of non-sterile gloves
 Special Precautions: When using PHMB, wet the cleaning cloth with the
solution and apply it to the entire surface as described in the procedure;
no rinsing is necessary; allow to air dry; wait for approximately 5 minutes
before releasing and contacting the patient.

2. Cleaning with neutral detergent and disinfection with alcohol solution:

 2 containers for the procedure, one for cleaning and another for rinsing
 Hamper
 Water and neutral liquid soap or detergent
 70% liquid alcohol
 Disposable cleaning cloths
 Paper towels
 2 pairs of non-sterile gloves
Procedures
Rotine Cleaning:
1. Perform hand hygiene and put on PPE, if indicated;
2. Explain to other patients in the hospital unit what will be done;
3. Open doors and windows to allow for ventilation;
4. Check what belongs to the patient unit where concurrent cleaning will take place: bed, bedside
table, chair, step ladder, IV pole, call bell, and gas outlets;
5. Remove the bed linen and place it in the hamper;
6. Put on gloves;
7. Start cleaning with gas outlets, call bell, IV pole, bedside table, exposed parts of the bed, chair,
and step ladder;
8. Use unidirectional movements horizontally and top to bottom vertically (from cleaner to dirtier);
9. Make the bed;
10. Arrange the patient unit by returning materials to appropriate places;
11. Remove gloves;

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 12. Remove additional PPE, if used.
13. Perform hand hygiene.

Figure 1 - Example of a cleaning strategy from cleaner to dirtier areas

Font: CDC (2020). Available at: [Link]
[Link]

Terminal Cleaning:
1. Perform hand hygiene and put on PPE, if indicated;
2. Explain to other patients on the hospital unit what will be done;
3. Open doors and windows to ventilate the room;
4. Check the patient's unit to be cleaned and disinfected for items such as bed (mattress, pillow, and
waterproof cover), bedside table, chair, step stool, IV pole, call bell, and gas outlet;
5. Gather the necessary cleaning supplies and bring them to the patient's unit;
6. Put on two pairs of gloves (one over the other) or use only one pair and change them if they
become damp or punctured;
7. Remove the bedding and put it in the hamper;
8. Remove all items from the bedside table and dispose of them appropriately;
9. Place two containers of water and a bottle of detergent on the chair;
10. Move the bed away from the wall and lock the wheels;
11. Clean the gas outlet, call bell, and IV pole (clean with water and detergent first and then follow
these steps for the other objects);
12. Always use unidirectional horizontal motions and top-to-bottom vertical motions (from cleanest
to dirtiest);
13. Clean the inside and outside of the bedside table;
14. Clean the exposed side of the pillow and place it on the bedside table with the clean side up;
15. Clean the other side of the pillow;
16. Note: the use of waterproof covers is not recommended, but if the institution still uses them,
follow these steps: lay the waterproof cover lengthwise over the mattress, clean the exposed side
of the cover, fold it in half, place it on the back of the chair; clean the top (exposed) and sides
(right and left) of the mattress, open the waterproof cover over the mattress lengthwise with the
clean side facing down, clean the exposed side of the cover, fold it and place it on the pillow;
17. Fold the mattress in half and place it on the lower part of the bed, exposing the upper half of the
bed frame;
18. Clean the headboard, bed frame, and exposed half of the mattress, operate the crank handle and
clean under the bed;
19. Stretch the mattress back onto the bed and fold it in the opposite direction as before, exposing
the lower half of the bed frame;
20. Clean the bed frame and the other half of the mattress that is exposed, operate the crank
handles, clean them, and then clean under the bed;
21. Return the mattress to its original position;
22. Clean the sides and feet of the bed;

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 23. Line the step stool with paper towels and place the basin on it;
24. Clean the chair;
25. Line the chair with paper and place the basin on it;
26. Clean the step stool;
27. Position the unit's equipment;
28. After cleaning with water and detergent, disinfect all surfaces three times with 70% alcohol
(according to hospital infection control guidelines);
29. Reassemble the patient's unit;
30. Remove gloves;
31. Remove additional PPE, if used;
32. Perform hand hygiene;
33. Place the notice - Unit disinfected (name, position, date, and time).
Nursing Documentation
Not applicable.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Centers for Disease Control and Prevention (2020). Environmental Cleaning Procedures: Best
Practices for Environmental Cleaning in Global Healthcare Facilities with Limited Resources.
Available at: [Link]
Access at: May 22, 2023.
3. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis: Elsevier;
2021.
4. 3. Lynn P. Taylor's Clinical Nursing Skills: a nursing process approach. 5ª ed. Philadelphia: Wolters
Kluwer; 2019. 3830 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023

3/2
 Attachment D:
BODY MECHANICS AND ERGONOMICS
Related Course(s) Clinical skills
Theoretical content Body Mechanics and Ergonomics
Definition Body mechanics is the term used to describe the efficient, coordinated, and safe
use of the body to move objects and carry out activities of daily living.
Rationale To achieve an acceptable balance between mobility and
stability that will not place undue strain on the musculoskeletal system.
Principles • The wider the base of support the lower the center of gravity, the greater
the stability and balance of the object or person.
• When a person moves the center of gravity shifts in the direction of the
movement, the closer the line of gravity is to the center of the base of
support the greater the stability. If the line of gravity falls outside the
base of support the person would fall.
• The center of gravity can be lowered by flexing the hip and knees
assuming a squatting position.
• When a person moves, the center of gravity shifts continuously in the
direction of the moving body parts.
• Balance depends on the interrelationship of the center of gravity, the line
of gravity, and the base of support.
• The closer the line of gravity is to the center of the base of support, the
greater the person’s stability. Conversely, the closer the line of gravity is
to the edge of the base of support, the more precarious the balance. If
the line of gravity falls outside the base of support, the person falls.
Requisities  Risk assessment forms
 Mechanical aids, e.g., a lifting device, patient sling or sliding sheets
Assessment:
Rule 1: Knowing the Patient's Conditions and the Required or Necessary Position. The following aspects
should be assessed:
 General state of the patient, degree of mobility and consciousness, diagnosis;
 Presence of contractures, flaccid muscles, painful areas, infections, redness, edema, bone
injuries, absence or decreased sensitivity, weakness, paralysis;
 Patient's weight;
 Presence of equipment and devices monitoring the patient;
 Urinary and/or fecal incontinence, presence of secretion or fluid collection devices;
 Presence of catheters, splints;
 Adoption of incorrect postures in bed and biased positions, such as equinus foot;
 Allowed movements, required and necessary position for the patient;
 Scheduled times for movement.

Rule 2: Knowing the Environment and Available Resources. The environment and available resources are
relevant for planning how the task will be performed:
 Physical space: there should be enough space between beds to allow the movement of nursing
staff and the manipulation of chairs and stretchers;
 Floor conditions: the floor should not be slippery or wet;
 Bed height: the height should be adjusted to approximately 5 cm from the height of the elbow of
the activity performers. For this reason, beds with adjustable heights are recommended;
 Existence of side rails on the bed for patient protection against falls;
 Type of mattress: thin, smooth, water mattresses make movement difficult;
 Number of available professionals: movement should be performed by two, three, or four
professionals. Only in situations where the patient can cooperate, a nurse may perform the
movement;

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  Technological resources and available equipment. The use of patient lifts can facilitate the
transfer of patients from bed to stretcher, bed to chair, and vice versa.

Rule 3: Use the principles of Ergonomics and Biomechanics to perform the activity in order to prevent
harm to the health of nursing workers. A significant portion of back injuries and pain can be prevented if
nursing workers use proper body mechanics by adopting good posture when moving and lifting patients,
and if the working conditions are suitable for the psychophysiological characteristics of the workers. The
following principles should be observed:
 Maintain a straight back. This is achieved by bending the knees and using voluntary action of the
striated muscles to support the back. This ensures that pressure on the intervertebral discs is
evenly distributed. Note: However, if there is a need to lean the torso, ensure that the spine
does not become arched;
 Avoid trunk twists as they cause undesirable tension and asymmetric loads on the vertebrae;
 Muscles should always be slightly contracted. Prepare the muscles for action before the activity
to protect ligaments and muscles from injuries. To lift weight, contract the abdominal and gluteal
muscles;
 Assume a wide base stance and bend the knees. Stability is greater when the feet are about 25
to 30 cm apart;
 Use your own body weight to counterbalance the weight of the patient, requiring less energy for
movement;
 The force needed to maintain body balance is greater when the center of gravity is as far away as
possible from the center of the support base. Therefore, a person who holds a weight close to
their body exerts less effort than someone who holds the weight with extended arms;
 The bed height should be adjusted based on the level of the performers' elbow, with a suitable
distance of about 5 cm between the bed height and the elbow height;
 Use palm grip, not fingertips, to hold objects and patients;
 The individual load that each person can carry individually is up to 23 kg. To lift or carry obese
patients, it requires two or three nursing workers of the same anthropometric standard,
meaning the same height, to enable proper weight distribution.
 There should always be a minimum of two nurses to move a patient when the
person being moved cannot fully bear weight, and/or a mechanical aid such as a
hoist should be used.
Procedures:
1. Assess and plan the moving and handling requirements of patients with regard to their physical
and psychological condition, weight and ability to help, the environment, the number of helpers
and the most appropriate mechanical aids. This assessment and plan should be detailed in the
patient's care plan and be frequently reviewed as the patient's condition changes;
2. If possible, clear the area of any obstacles, for ease of movement;
3. Ensure an appropriate bed height to reduce the risk of back injury;

Figure 1 - Examples of safe and unsafe lifting

Font: Jamieson, E.M., J.M. McCall, and L.A. Whyte, Clinical nursing practices. 4th ed. 1988, Edinburgh:

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 Churcill Livingstone. 450p.
4. Collect any help and/or mechanical aids required to reduce any risk involved;
5. Explain fully to the patient and any helpers what is going to happen and what is expected of
them so that they can co-operate as much as possible;
6. Observe the patient throughout this activity to detect any signs of distress. When patients know
exactly what is going to happen to them, they should be more relaxed and co-operative, and this
should lessen the risk of injury for both them and staff;

Figure 2 - Examples of mechanical aids

Font: Jamieson, E.M., J.M. McCall, and L.A. Whyte, Clinical nursing practices. 4th ed. 1988, Edinburgh:
Churcill Livingstone. 450p.

7. Adopt a suitable position for the move, or maneuver the mechanical aid into position for the
move;
8. Apply the recommended theories of safe and efficient moving and handling practice when
performing the move, to protect nursing staff from back injury;
9. Carry out the move, one nurse acting as leader and giving instructions so that everyone knows
what is expected of them and can act together;
10. Ensure that the patient is left feeling as comfortable as possible;
11. Clean any equipment used, to reduce the risk of cross-infection, and replace it in its storage
position so that it is accessible to other members of staff;
12. In undertaking this practice, nurses are accountable for their actions, the quality of care
delivered and record-keeping according to the Code of Professional Conduct and Guidelines for
Professional Practice.
Nursing documentation
Date and Time: Performed the movement and transfer of patient M.S., diagnosed with a hip fracture,
from the bed to the stretcher using a patient lift. The nursing team consisted of three experienced
nurses. The bed height was adjusted to be approximately at the level of the elbows of the executing staff,
ensuring a comfortable and safe posture. The stability of the stretcher was also checked, and the brakes
were adjusted to prevent unwanted movements. The patient cooperated during the transfer process,
following the team's instructions. Throughout the procedure, clear and reassuring communication was
maintained with the patient, providing the necessary emotional support. After the transfer, the patient's
position on the stretcher was verified to ensure comfort and safety. A new assessment of the patient was
conducted to identify possible discomfort or additional care needs. The movement and transfer were
successfully completed without any incidents or complications. The patient was securely accommodated
on the stretcher, ready for transportation to the examination area. Name of the professional, position,
and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Jamieson, E.M., J.M. McCall, and L.A. Whyte, Clinical nursing practices. 4th ed. 1988, Edinburgh:
Churcill Livingstone. 450p.
3. 3. Marziale, M.H.P., Movement and transfer of bedridden patients based on the ergonomics
framework. 2000, University of São Paulo at Ribeirão Preto College of Nursing: Ribeirão Preto.

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 Available at: [Link]
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

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 Attachment E1:
ASSISTING A CLIENT TO AMBULATE
Related Course(s) Clinical skills
Theoretical content Moving
Positioning
Lifting and turning patients
Definition Ambulation is defined as moving a patient from one place to another. Once a
patient is assessed as safe to ambulate, the nurse must determine if assistance
from additional healthcare providers or assistive devices is required.
Rationale To provide a safe condition for the client to walk with whatever support is
needed.
Principles  Immobility in hospitalized patients is known to cause functional decline
and complications affecting the respiratory, cardiovascular,
gastrointestinal, integumentary, musculoskeletal, and renal systems.
 For surgical patients, early ambulation is the most significant factor in
preventing complications.
 Lack of mobility and ambulation can be especially devastating to the
older adult when the aging process causes a more rapid decline in
function.
 Ambulation provides not only improved physical function, but also
improves emotional and social well-being.
 Prior to assisting a patient to ambulate, it is important to perform a
patient risk assessment to determine how much assistance will be
required.
 An assessment can evaluate a patient’s muscle strength, activity
tolerance, and ability to move, as well as the need to use assistive devices
or find additional help.
 The amount of assistance will depend on the patient’s condition, length
of stay and procedure, and any previous mobility restrictions.
 Patients who have been immobile for a long period of time may
experience vertigo, a sensation of dizziness, and orthostatic hypotension,
a form of low blood pressure that occurs when changing position from
lying down to sitting, making the patient feel dizzy, faint, or lightheaded.
For this reason, always begin the ambulation process by sitting the
patient on the side of the bed for a few minutes with legs dangling.
Requisities 1. Gait belt, as necessary
2. Nonskid shoes or slippers
3. Nonsterile gloves and/or other PPE, as indicated
4. Stand-assist device, as necessary, if available
5. Additional staff for assistance, as needed
Assessment:
 Assess the patient’s ability to walk and the need for assistance.
 Review the patient’s record for conditions that may affect ambulation.
 Perform a pain assessment before the time for the activity. If the patient reports pain, administer
the prescribed medication in sufficient time to allow for the full effect of the analgesic.
 Take vital signs and assess the patient for dizziness or lightheadedness with position changes.
Procedures:
1. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move and ambulate. Assess for tubes, IV lines, incisions, or equipment that
may alter the procedure for ambulation. Identify any movement limitations;
2. Perform hand hygiene and put on PPE, if indicated;
3. Identify the patient;

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 4. Introduce yourself;
5. Explain procedure to patient to gain consent;
6. Ask the patient to report any feelings of dizziness, weakness, or shortness of breath while
walking;
7. Decide how far to walk;
8. Place the bed in the lowest position;
9. Encourage the patient to make use of a stand-assist aid, either free-standing or attached to the
side of the bed, if available, to move to the side of the bed.
10. Assist the patient to the side of the bed, if necessary;
11. Have the patient sit on the side of the bed for several minutes and assess for dizziness or
lightheadedness. Have the patient stay sitting until he or she feels secure;
12. Assist the patient to put on footwear and a robe, if desired;
13. Wrap the gait belt around the patient’s waist, based on assessed need and facility policy;
14. Encourage the patient to make use of the stand-assist device. Assist the patient to stand, using
the gait belt, if necessary. Assess the patient’s balance and leg strength. If the patient is weak or
unsteady, return the patient to bed or assist to a chair;
15. If you are the only nurse assisting, position yourself to the side and slightly behind the patient.
Support the patient by the waist or transfer belt. When two nurses assist, position yourself to
the side and slightly behind the patient, supporting the patient by the waist or gait belt. Have the
other nurse carry or manage equipment or provide additional support from the other side.
Alternatively, when two nurses assist, stand at the patient’s sides (one nurse on each side) with
near hands grasping the gait belt and far hands holding the patient’s lower arm or hand;

Figure 1 - Assisting a client to ambulate

Font: Lynn P. Taylor's Handbook of Clinical Nursing Skills. 1st ed. Philadelphia: Wolters Kluwer; 2011. 990
p.

16. Take several steps forward with the patient. Continue to assess the patient’s strength and
balance. Remind the patient to stand erect;
17. Continue with ambulation for the planned distance and time;
18. Return the patient to the bed or chair, based on the patient’s tolerance and condition;
19. Remove gait belt;
20. Clean transfer aids, per facility policy, if not indicated for single patient use;
21. Remove gloves and any other PPE, if used;
22. Perform hand hygiene;
23. Document the care provided.
Nursing documentation
Date and Time: Assisted the client to ambulate. The patient presented limited capacity to assist in
ambulation. A walker and two team members were used for transfer. During ambulation, the patient
reported anxiety and mild discomfort but tolerated the walk without difficulty. The patient was able to

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walk a distance of 20 meters without signs of dizziness or vertigo. After the activity, the patient was
reassessed and reported improvement in mobility and overall well-being. Name of the professional,
position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Perry AGP, Potter PA, Ostendorf WR. Nursing interventions & clinical skills. 7th ed. St Louis:
Elsevier; 2020. 2196 p.
3. Lynn P. Taylor's Handbook of Clinical Nursing Skills. 1st ed. Philadelphia: Wolters Kluwer; 2011.
990 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

3/2
 Attachment E2:
ASSISTING A CLIENT TO SIT ON A SIDE OF THE BED
Related Course(s) Clinical skills
Theoretical content Moving
Positioning
Lifting and turning patients
Definition The procedures involved to help the client to assume a sitting position on the
edge of the bed before walking, moving to a chair or wheelchair, eating, or
performing other activities.
Rationale  To help the client to assume a sitting position on the edge of the bed
before walking, moving to a chair or wheelchair, eating, or performing
other activities.
Principles  Immobility in hospitalized patients is known to cause functional decline
and complications affecting the respiratory, cardiovascular,
gastrointestinal, integumentary, musculoskeletal, and renal systems.
 Lack of mobility can be especially devastating to the older adult when the
aging process causes a more rapid decline in function.
 Patients who have been immobile for a long period of time may
experience vertigo, a sensation of dizziness, and orthostatic hypotension,
a form of low blood pressure that occurs when changing position from
lying down to sitting, making the patient feel dizzy, faint, or lightheaded.
For this reason, always begin the process by sitting the patient on the side
of the bed for a few minutes with legs dangling.
Requisities Assistive devices
Assessment:
Determine:
 Assistive devices that will be required.
 Limitations to movement such as an IV or a urinary catheter.
 Medications the client is receiving, because certain medications may hamper movement or
alertness of the client.
 Assistance required from other healthcare personnel.
Procedures:
1. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move;
2. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for siting on a side
of the bed;
3. Identify any movement limitations;
4. Perform hand hygiene and put on PPE, if indicated;
5. Identify the patient;
6. Introduce yourself;
7. Explain procedure to patient to gain consent;
8. Provide for client privacy;
9. Position yourself and the client appropriately before the move;
10. Assist the client to a lateral position facing you, using an assistive device depending on client
assistance needs;
11. Raise the head of the bed slowly to its highest position. This decreases the distance that the
client needs to move to sit up on the side of the bed;
12. Position the client’s feet and lower legs at the edge of the bed. This enables the client’s feet to
move easily off the bed during the movement, and the client is aided by gravity into a sitting
position;
13. Stand beside the client’s hips and face the far corner of the bottom of the bed (the angle in which
movement will occur);
14. Assume a broad stance, placing the foot nearest the client and head of the bed forward. Lean

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 your trunk forward from the hips. Flex your hips, knees, and ankles;
15. Move the client to a sitting position, using an assistive device depending on client assistance
needs;
16. Place the arm nearest to the head of the bed under the client’s shoulders and the other arm over
both of the client’s thighs near the knees. Supporting the client’s shoulders prevents the client
from falling backward during the movement. Supporting the client’s thighs reduces friction of the
thighs against the bed surface during the move and increases the force of the movement;
17. Tighten your gluteal, abdominal, leg, and arm muscles;
18. 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. Pivoting prevents twisting of the nurse’s spine. The weight of
the client’s legs swinging downward increases downward movement of the lower body and helps
make the client’s upper body vertical;
19. Keep supporting the client until the client is well balanced and comfortable. This movement may
cause some clients to become light-headed or dizzy;
20. Assess vital signs (e.g., pulse, respirations, and blood pressure) as indicated by the client’s health
status;

Figure 1 - Helping the client to assume a sitting position on the edge of the bed
Font: Berman, A., S. Snyder, and G. Frandsen, Kozier & Erb's Fundamentals of Nursing: concepts, process
and practice. 11th ed. 2022, United Kingdom: British Library. 1553.

21. Remove gloves and any other PPE, if used;

22. Perform hand hygiene;
23. Document all relevant information:
• 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 (e.g., anxiety, discomfort, dizziness).
Nursing documentation
Date and Time: Assisted a client to sit on a side of the bed. The client had some difficulty in moving, but
was able to cooperate during the process. An assistive device (hospital bed) was used to help the client
sit on the side of the bed. During the position change, the client reported mild discomfort but was able to
tolerate it well. No signs of anxiety or dizziness were observed during the process. Name of the
professional, position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis: Elsevier;
2021.

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 3. Lynn, P., Taylor's Clinical Nursing Skills: a nursing process approach. 5ª ed. 2019, Philadelphia:
Wolters Kluwer. 3830 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

3/2
 Attachment E3:
MOVING A CLIENT UP IN BED
Related Course(s) Clinical skills
Theoretical content Moving
Positioning
Lifting and turning patients
Definition The procedures involved to move a client up in bed.
Rationale  To assist clients who have slid down in bed from the Fowler’s position to
move up in bed.
Principles  Immobility in hospitalized patients is known to cause functional decline
and complications affecting the respiratory, cardiovascular,
gastrointestinal, integumentary, musculoskeletal, and renal systems.
 Lack of mobility can be especially devastating to the older adult when the
aging process causes a more rapid decline in function.
 Patients who have been immobile for a long period of time may
experience vertigo, a sensation of dizziness, and orthostatic hypotension,
a form of low blood pressure that occurs when changing position from
lying down to sitting, making the patient feel dizzy, faint, or lightheaded.
For this reason, always begin the process by sitting the patient on the side
of the bed for a few minutes with legs dangling.
Requisities  Assistive devices such as an overhead trapeze, friction-reducing device, or
a mechanical lift.
Assessment
Before moving a client, assess the following:
 Client’s ability to lie flat or contraindications to lie flat (e.g., respiratory status).
 Client’s physical abilities to assist with the move (e.g., muscle strength, presence of paralysis).
 Client’s ability to understand instructions and willingness to participate.
 Client’s degree of comfort or discomfort when moving; if needed, administer analgesics or
perform other pain relief measures prior to the move.
 Client’s weight.
 The availability of equipment and other personnel to assist you.
Procedures:
1. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move;
2. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for moving the
patient up in bed;
3. Identify any movement limitations;
4. Perform hand hygiene and put on PPE, if indicated;
5. Identify the patient;
6. Introduce yourself;
7. Explain procedure to patient to gain consent;
8. Provide for client privacy;
9. Adjust the bed and the client’s position.
 Adjust the head of the bed to a flat position or as low as the client can tolerate. Rationale:
Moving the client upward against gravity requires more force and can cause back strain.
 Raise the bed to a height appropriate for personnel safety (i.e., at the caregiver’s elbows).
 Lock the wheels on the bed and raise the rail on the side of the bed opposite you.
 Remove all pillows, then place one against the head of the bed. Rationale: This pillow protects
the client’s head from inadvertent injury against the top of the bed during the upward move.
10. For the client who is able to reposition without assistance:
 Place the bed in flat or reverse Trendelenburg’s position (as tolerated by the client). Stand by
and instruct the client to move self. Assess if the client is able to move without causing
friction to the skin.

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  Encourage the client to reach up and grasp the upper side rails with both hands, bend knees,
and push off with the feet and pull up with the arms simultaneously.
 Ask if a positioning device is needed (e.g., pillow).
11. For the client who is partially able to assist:
 For a client who weighs less than 200 pounds: Use a friction-reducing device and two
assistants. Rationale: Moving a client up in bed is not a one-person task. During any client
handling, if the caregiver is required to lift more than 35 lb of a client’s weight, then the client
should be considered fully dependent and assistive devices should be used. This reduces risk
of injury to the caregiver.
 For a client who weighs between 201–300 pounds: Use a friction-reducing slide sheet and
four assistants OR an air transfer system and two assistants. Rationale: Moving a client up in
bed is not a one-person task. During any client handling, if the caregiver is required to lift
more than 35 lb of a client’s weight, then the client should be considered fully dependent and
assistive devices should be used. This reduces risk of injury to the caregiver.
 For a client who weighs more than 300 pounds: Use an air transfer system and two assistants
OR a total transfer lift.
 Ask the client to flex the hips and knees and position the feet so that they can be used
effectively for pushing. Rationale: Flexing the hips and knees keeps the entire lower leg off the
bed surface, preventing friction during movement, and ensures use of the large muscle
groups in the client’s legs when pushing, thus increasing the force of movement.
 Place the client’s arms across the chest. Ask the client to flex the neck during the move and
keep the head off the bed surface. Rationale: This keeps the arms and head off the bed
surface and minimizes friction during movement.
 Use the friction-reducing device and assistants to move the client up in bed. Ask the client to
push on the count of three.
12. Position yourself appropriately, and move the client:
 Face the direction of the movement, and then assume a broad stance with the foot nearest
the bed behind the forward foot and weight on the forward foot. Lean your trunk forward
from the hips. Flex the hips, knees, and ankles.
 Tighten your gluteal, abdominal, leg, and arm muscles and rock from the back leg to the front
leg and back again. Then, shift your weight to the front leg as the client pushes with the heels
so that the client moves toward the head of the bed.
13. For the client who is unable to assist:
 Use the ceiling lift with supine sling or mobile floor-based lift and two or more caregivers.
Follow manufacturer’s guidelines for using the lift. Rationale: Moving a client up in bed is not
a one-person task. During any client handling, if the caregiver is required to lift more than 35
lb of a client’s weight, then the client should be considered to be fully dependent, and
assistive devices should be used. This reduces risk of injury to the caregiver.
14. Ensure client comfort:
 Elevate the head of the bed and provide appropriate support devices for the client’s new
position.
 See the sections on positioning clients earlier in this chapter.
15. Remove gloves and any other PPE, if used;
16. Perform hand hygiene;
17. Document all relevant information:
 Time and change of position moved from and position moved to;
 Any signs of pressure areas;
 Use of support devices;
 Ability of client to assist in moving and turning;
 Response of client to moving and turning (e.g., anxiety, discomfort, dizziness).
Nursing document
Date and Time: Performed a procedure of moving a client up in bed. The patient's initial position was
lying on their back with the head of the bed elevated to 30 degrees, and in the final position the head of
the bed was elevated to 45 degrees. No support devices were used during the procedure. There were no

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signs of pressure areas. The patient had difficulty moving and required assistance during the procedure.
The patient reported mild discomfort in the lumbar region, but did not have any other complaints or
signs of anxiety or dizziness. Name of the professional, position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis: Elsevier;
2021.
3. Lynn, P., Taylor's Clinical Nursing Skills: a nursing process approach. 5ª ed. 2019, Philadelphia:
Wolters Kluwer. 3830 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

3/2
 Attachment E4:
BED POSITIONS: LATERAL AND PRONE
Related Course(s) Clinical skills
Theoretical content Moving
Definition The procedures involved to move a client to lateral and prone positions.
Rationale  To position and maintain patients’ body alignment and comfort.
 To provide frequent repositioning to avoid physical complications,
including pressure injuries, reduced ventilation, and muscle contractures.
Principles  Immobility in hospitalized patients is known to cause functional decline
and complications affecting the respiratory, cardiovascular,
gastrointestinal, integumentary, musculoskeletal, and renal systems.
 Lack of mobility can be especially devastating to the older adult when the
aging process causes a more rapid decline in function.
 Patients who have been immobile for a long period of time may
experience vertigo, a sensation of dizziness, and orthostatic hypotension,
a form of low blood pressure that occurs when changing position from
lying down to sitting, making the patient feel dizzy, faint, or lightheaded.
For this reason, always begin the process by sitting the patient on the side
of the bed for a few minutes with legs dangling
Requisities  Pillows, drawsheet
 Appropriate safe patient handling assistive devices (e.g., friction reducing
device, ceiling lift, or mechanical floor lift)
 Therapeutic boots/splints (optional)
 Trochanter rolls (optional)
 Hand rolls
 Clean gloves
Assessment
 Identify patient using at least two identifiers (e.g., name and birthday or name and medical
record number) according to agency policy.
 Refer to medical record for most recent recorded weight and height for patient. Factors help to
determine if mechanical lift, mechanical transfer device, or friction-reducing device is needed for
moving patient up in bed.
 Check health care provider's orders for any restrictions in movement before positioning patient.
 Assess patient's range of motion (ROM) and current body alignment while patient is lying down.
 Assess for risk factors that contribute to complications of immobility. Rationale: Risk factors
require patient to be repositioned more frequently:
 Reduced sensation: Cerebrovascular accident (CVA), spinal cord injury, or neuropathy.
Rationale: With reduced sensation, a patient has difficulty moving, has poor awareness of
involved body part, and is unable to position body part and protect it from pressure.
 Impaired mobility: Traction, arthritis, CVA, spinal cord injury, hip fracture, joint surgery, or
other contributing disease processes. Rationale: Traction, bone fractures, surgery, or arthritic
changes result in decreased ROM. Loss of function caused by CVA or spinal injury can lead to
contractures.
 Impaired circulation: Arterial insufficiency. Rationale: Decreased circulation predisposes
patient to pressure injury.
 Age: Very young, older adult. Rationale: Premature and young infants require frequent
turning because their skin is fragile. Normal physiological changes of aging predispose to
greater risks for developing complications of immobility.
 Assess patient's level of consciousness.
 Assess patient for presence of pain; rate on scale of 0 to 10.
 Assess condition of patient's skin, especially over bony prominences.
 Assess patient's physical ability to help with moving and positioning, which may be affected by
age, level of consciousness, disease process, strength, ROM, and coordination.

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  Assess patient's vision and hearing.
 Apply clean gloves (as needed) to assess for presence of incisions, drainage tubes, and
equipment (e.g., traction).
 Empty drainage bags before positioning.
 Assess motivation of patient and ability of family caregivers to participate in moving and
positioning if patient to be discharged home.
 Assess patient's or family caregiver's knowledge, experience, and health literacy.

Planning
 Expected outcomes following completion of procedure:
 Patient retains ROM.
 Patient's skin shows no evidence of breakdown.
 Patient's comfort level increases.
 Patient's level of independence in completing activities of daily living increases.
 If patient perceives level of pain to be enough to avoid movement, offer an analgesic 30 minutes
(if ordered) before repositioning.
 Remove all pillows and devices used in previous position.
 Get additional caregivers and/or necessary lift or transfer device to perform positioning.
 Explain positioning procedure to patient using plain language.
 Close door to room or bedside curtains.
Procedures:
Lateral position:
1. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move;
2. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for siting on a side
of the bed;
3. Identify any movement limitations;
4. Perform hand hygiene and put on PPE, if indicated;
5. Identify the patient;
6. Introduce yourself;
7. Explain procedure to patient to gain consent;
8. Provide for client privacy;
9. Raise level of bed to comfortable working height, level with your elbows;
10. Assist patient to move up in bed:
 Determine if the patient can assist:
a) Patient is fully able to assist:
 Stand at bedside to help with positioning of tubing and equipment as patient moves.
 Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and,
on a count of three, lift hips up and push legs so body moves up in bed.

b) Patient is partially able to assist:

 Encourage patient to help using friction-reducing device (e.g., slide board)
 Patient weighs less than 91 kg (200 lb): use friction-reducing sheet or slide board and
two or three caregivers.
 Patient weighs greater than 91 kg (200 lb): use friction-reducing device and at least
three caregivers.
i. Using a friction-reducing device (three nurses). Position patient supine with head
of bed flat. A nurse stands on each side of bed.
ii. Remove pillow from under head and shoulders and place it at head of bed.
iii. Turn patient side to side to place friction-reducing device under drawsheet on bed,
with device extending from shoulders to thighs/ankles.
iv. Return patient to supine position.
v. Have two caregivers grasp drawsheet (one on each side of bed) firmly and have
third nurse hold on to end of friction-reducing device.

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 vi. Place feet apart with forward-backward stance. Flex knees and hips. On count of
three, shift weight from front to back leg and move patient and drawsheet to
desired position up in bed
c) Patient unable to assist:
 Use appropriate number of caregivers and appropriate safe patient-handling devices
(e.g., supine sling with ceiling lift or floor-based lift and two or more caregivers) to
move and position patient.
11. Position patient in bed in one of the following positions while ensuring correct body
alignment;
12. Protect pressure areas:
 Determine if patient can assist.
 Begin with patient lying supine and move up in bed.

Position patient in the lateral position from Fowler’s:

13. Lower the head of the bed to the lowest position tolerated by the client. Lowering the head of
the bed reduces the force needed to move the client and therefore decreases the risk of nurse
injury. Fighting the law of gravity is a losing battle.
14. Position the client’s hips on the side of the bed closest to you. Beginning to roll on one side of the
bed allows room to turn and position the arms and legs.
15. Position the client’s arm nearest you across the client’s chest. Positioning the arm in the direction
the client will roll facilitates the roll
16. Position the client’s far arm abducted from the client’s body with the client’s hand up at head
level. This is the direction the client will roll; therefore, abducting the arm and raising the hand
prevents the client from rolling on top of the arm and hand.
17. Position the client’s leg nearest you over the other leg. Positioning the leg in the direction the
client will roll facilitates the roll.

If you are alone:

18. Raise the side rail on the near side where the client’s hips are closest to the edge of the bed.
19. Walk around the bed to the far side.
20. Place one hand on the client’s far shoulder and far hip to roll the client. Holding the hip and
shoulder gives control over the client’s torso.

If you are working with a colleague:

21. The nurse on the far side places one hand on the client’s far shoulder and far hip. Holding the hip
and shoulder gives control over movement of the client’s torso;
22. The nurse on the near side assists the client to lift the head and, if the client has long hair,
protects the hair. Lifting the head reduces friction, and moving the hair prevents pulling;
23. Place one foot under the edge of the bed and the other foot behind with a broad stance;
24. Flex your knees and hips with your weight over the foot closest to the bed. Flexing your knees
and hips engages the gluteal and quadriceps muscles and reduces stress on your back;
25. Coordinate the move with your colleague. Typically, nurses count to three, then move.
Coordinating movement maximizes your efforts and reduces the risk of injury;
26. Tighten your core muscles and transfer your weight to the back foot. Keep your arms in close to
your body. Working close to the body prevents hyperextension and reduces the risk of injury;
27. Roll the client into a lateral position;
28. Position pillows under the client’s head to support the head and neck and maintain a neutral
position without lateral flexion of the neck;
29. Position pillows under the upper arm to support the shoulder and arm in alignment and to
prevent internal rotation;
30. Position pillows under the upper leg to support the leg and hip in alignment and to prevent
internal rotation;

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 Figure 1 – Lateral position
Font: Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.

Position patient in the prone position:

31. Lower the head of the bed to the lowest position tolerated by the client. Lowering the head of
the bed reduces the force needed to move the client and therefore decreases the risk of nurse
injury. Fighting the law of gravity is a losing battle;
32. Remove pillows and place them on a clean, dry surface. Positioning is easier with pillows
removed and then repositioned to support the client;
33. Position the client on a friction-reducing surface, as needed. Friction-reducing surfaces greatly
reduce the force needed to move clients;
34. Position the client’s hips on the side of the bed closest to you. Beginning to roll on one side of the
bed allows room to turn and position the arms and legs;
35. Position the client’s arm nearest you across the client’s chest. Positioning the arm in the direction
the client will roll facilitates the roll;
36. Position the client’s dependent arm close to the client’s body. This is the direction the client will
roll. Keeping the arm close to the body allows the client to roll over the arm;
37. Position the client’s leg nearest you over the other leg. Positioning the leg in the direction the
client will roll facilitates the roll;

If you are alone:

38. Raise the side rail on the near side where the client’s hips are closest to the edge of the bed;
39. Walk around the bed to the far side;
40. Place one hand on the client’s far shoulder and far hip. Holding the hip and shoulder gives
control over the client’s torso (go to item 57 to finish the skill).

If you are working with a colleague:

41. The nurse on the far side places one hand on the client’s far shoulder and far hip. Holding the hip
and shoulder gives control over movement of the client’s torso;
42. The nurse on the near side assists the client to lift the head and, if the client has long hair,
protects the hair. Lifting the head reduces friction, and moving the hair prevents pulling;
43. Place one foot under the edge of the bed and the other foot behind with a broad stance;
44. Flex your knees and hips with your weight over the foot closest to the bed. Flexing your knees
and hips engages the gluteal and quadriceps muscles and reduces stress on your back;
45. Coordinate the move with your colleague. Typically, nurses count to three, then move.
Coordinating movement maximizes your efforts and reduces the risk of injury;
46. Tighten your core muscles and transfer your weight to the back foot. Keep your arms in close to
your body. Working close to the body prevents hyperextension and reduces the risk of injury;
47. Roll the client into a prone position;
48. Position the client’s head turned to one side. If a pillow is used, it must be a very flat one to
prevent hyperflexion of the neck;
49. The arms may be comfortably positioned at the client’s side or up at the head level;
50. Position a small pillow under the abdomen to support the lumbar curvature;
51. Position a small pillow under the lower legs or allow the feet to fall over the end of the mattress
to allow dorsiflexion and prevent plantar flexion (foot drop);

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 Figure 1 – Prone position
Font: Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.

52. Remove friction-reducing surface, if used;

53. Provide comfort. Assist the client with positioning, replace the pillows, and rearrange bedding;
54. Secure all medical equipment attached to the client and check for patency, such as intravenous
lines and Foley catheters. Equipment can become kinked or disconnected with client movement;
55. Ensure client safety. Place bed in the lowest position and verify that the client can identify and
reach the nurse call system. These safety measures reduce the risk of falls;
56. Evaluate outcomes. Your evaluation includes how the client tolerated the procedure and the
amount of assistance the client required to reposition;
57. Remove gloves and any other PPE, if used;
58. Perform hand hygiene;
59. Document the care provided.
Nursing documentation
Date and Time: Performed successful Prone Positioning on Mr. J. S, with the assistance of 4 professionals
for safe positioning. During the intervention, the patient reported moderate discomfort in the chest area,
which was promptly assessed and treated with analgesics as per medical prescription. Preventive
measures were taken to prevent pressure ulcers, including adequate protection of contact areas with
pressure relief devices. Vital signs, oxygen saturation, and respiratory function were reassessed after 30
minutes, with results within expected parameters. Name of the professional, position, and Guyana
Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Perry AGP, Potter PA, Ostendorf WR. Nursing interventions & clinical skills. 7th ed. St Louis:
Elsevier; 2020. 2196 p.
3. Stein LNM, Hollen CJ. Concept-based clinical nursing skills: fundamentals to advanced. St Louis:
Elsevier; 2021. 2776 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

5/2
 Attachment E5:
LOGROLLING A CLIENT
Related Course(s) Clinical skills
Theoretical content Moving
Definition Logrolling is a technique used to turn a client whose body must at all times be
kept in straight alignment (like a log). An example is the client with back surgery
or a spinal injury.
Rationale  To maintain alignment of the spine while turning and moving the patient
who has had spinal surgery or suspected or documented spinal injury.
Principles  Considerable care must be taken to prevent additional injury.
 This technique requires two nurses or, if the client is large, three
nurses.
 For the client who has a cervical injury, one nurse must
maintain the client’s head and neck alignment.
Requisities  Assistive devices such as a friction-reducing device or a mechanical lift
Assessment:
Determine:
 Assistive devices that will be required.
 Limitations to movement such as an IV or a urinary catheter.
 Medications the client is receiving, because certain medications may hamper movement or
alertness of the client.
 Assistance required from other healthcare personnel. At least 2–3 additional people are needed
to perform this skill safely.
Procedures:
1. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move;
2. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for siting on a side
of the bed;
3. Identify any movement limitations;
4. Perform hand hygiene and put on PPE, if indicated;
5. Identify the patient;
6. Introduce yourself;
7. Explain procedure to patient to gain consent;
8. Provide for client privacy;
9. Position yourselves and the client appropriately before the move;
10. Place the client’s arms across the chest. Doing so ensures that they will not be injured or become
trapped under the body when the body is turned;
11. Pull the client to the side of the bed:
 Use a friction-reducing device to facilitate logrolling. First, stand with another nurse on the
same side of the bed. Assume a broad stance with one foot forward, and grasp the rolled
edge of the friction-reducing device. On a signal, pull the client toward both of you.

Figure 1 - Logrolling a client

Font: Berman, A., S. Snyder, and G. Frandsen, Kozier & Erb's Fundamentals of Nursing: concepts, process
and practice. 11th ed. 2022, United Kingdom: British Library. 1553 p.

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  One nurse counts: “One, two, three, go.” Then, at the same time, all staff members pull the
client to the side of the bed by shifting their weight to the back foot. Rationale: Moving the
client in unison maintains the client’s body alignment.
12. One nurse moves to the other side of the bed, and places supportive devices for the client when
turned:
 Place a pillow where it will support the client’s head after the turn. Rationale: The pillow
prevents lateral flexion of the neck and ensures alignment of the cervical spine;
 Place one or two pillows between the client’s legs to support the upper leg when the client is
turned. Rationale: This pillow prevents adduction of the upper leg and keeps the legs parallel
and aligned;
13. Roll and position the client in proper alignment:
 Go to the other side of the bed (farthest from the client), and assume a stable stance.
 Reaching over the client, grasp the friction-reducing device, and roll the client toward you.

Figure 2 - Rolling and positioning the client in proper alignment

Font: Berman, A., S. Snyder, and G. Frandsen, Kozier & Erb's Fundamentals of Nursing: concepts, process
and practice. 11th ed. 2022, United Kingdom: British Library. 1553 p.

 One nurse counts: “One, two, three, go.” Then, at the same time, all nurses roll the client to a
lateral position;
 The second nurse (behind the client) helps turn the client and provides pillow supports to
ensure good alignment in the lateral position;
 Support the client’s head, back, and upper and lower extremities with pillows;
 Raise the side rails and place the call bell within the client’s reach;
14. Remove gloves and any other PPE, if used;
15. Perform hand hygiene;
16. Document all relevant information:
 Time and change of position moved from and position moved to;
 Any signs of pressure areas;
 Use of support devices;
 Ability of client to assist in moving and turning;
 Response of client to moving and turning (e.g., anxiety, discomfort, dizziness).
Nursing documentation
Date and Time: Performed logrolling with patient Mr. S.J, 65 years old, as per medical prescription. The
patient was moved from supine position to left lateral position, with the assistance of lateral support and
nursing. The patient was moved from supine to left lateral position. No signs of pressure areas were
identified. Lateral support and pillow were used to ensure stability and comfort during the position
change. The patient cooperated with the movement, demonstrating ability to move and change position.
During the process, the patient reported mild discomfort, but did not show signs of anxiety, significant
discomfort or dizziness. Name of the professional, position, and Guyana Nursing Registration.

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References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Groeneveld A, McKenzie ML, Williams D. Logrolling: establishing consistent practice. Orthop
Nurs. 2001 Mar-Apr;20(2):45-9. doi: 10.1097/00006416-200103000-00011
3. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis: Elsevier;
2021.
4. 3. Lynn, P., Taylor's Clinical Nursing Skills: a nursing process approach. 5ª ed. 2019, Philadelphia:
Wolters Kluwer. 3830 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

3/2
 Attachment E6:
TRANSFERING A CLIENT (BETWEEN BED AND CHAIR /
BETWEEN BED AND STRETCHER)
Related Course(s) Clinical skills
Theoretical content Moving
Moving
Positioning
Lifting and turning patients
Definition Transfers are defined as moving a patient from one flat surface to another, such
as from a bed to a stretcher. Types of hospital transfers include bed to stretcher,
bed to wheelchair, wheelchair to chair, and wheelchair to toilet, and vice versa.
Purpose  To transfer a client between the bed and a wheelchair or chair, the bed
and the commode, or a wheelchair and the toilet.
 There are numerous variations in the technique. Which variation the
nurse selects depends on factors related to the client and the
environment that are assessed prior to beginning the transfer.
 A client may need to be transferred between bed and stretcher with the
purpose to safely move supine clients from one location to another using
appropriate friction-reducing devices and a sufficient number of
caregivers depending on the client's weight and condition.
 Clients who are capable of independent transfer should be encouraged to
do so. Additional assistants may be needed depending on the client's
condition.
Principles  The most common patient transfers are from a bed to a stretcher and
from a bed to a wheelchair.
 While seemingly intuitive, successful patient transfers rely on
understanding each patient’s specific needs while simultaneously
adhering to evidence-based guidelines.
 Patient care transfers are an essential yet often neglected aspect of
patient care.
 Patient care transfers are an indispensable aspect of patient care,
requiring rigorous adherence to clinical guidelines.
 Proper transfers are based on the concept that focuses on maintaining
continuity of care both during and after the transfer.
 Depending on the complexity, patients often receive care in multiple
settings during and after hospitalization.
 While some aspects of patient transport vary depending on the patient’s
status, intrahospital transports are inevitable, particularly in critically ill
patients.
 Poorly organized patient transfers can result in increased morbidity and
mortality and should be performed with careful attention.
Requisities  Robe or appropriate clothing
 Slippers or shoes with nonskid soles
 Gait or transfer belt
 Stretcher
 Transfer assistive devices (e.g., slide sheet, transfer board, air transfer
system, lift)
Assessment:
Before transferring a client, assess the following:
 The client’s body size and weight.
 Ability to follow instructions.
 Ability to bear weight (full, partial, or none).
 Ability to position and reposition feet on floor.

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  Ability to push down with arms and lean forward.
 Ability to grasp.
 Ability to achieve independent balance (sitting, standing, or none).
 Activity tolerance.
 Muscle strength.
 Joint mobility.
 Presence of paralysis.
 Level of comfort.
 Presence of orthostatic hypotension.
 The technique with which the client is familiar.
 The space in which the transfer will need to be maneuvered (bathrooms, for example, are usually
cramped).
 The number of assistants (one or two) needed to accomplish the transfer safely.

Transferring Between Bed and Chair:

Preparation:
 Plan what to do and how to do it.
 Obtain essential equipment before starting (e.g., gait or transfer belt, wheelchair), and check that
all equipment is functioning correctly.
 Remove obstacles from the area so clients do not trip. Make sure there are no spills or liquids on
the floor on which clients could slip.
 Note any devices attached to the client (e.g., IV, urinary catheter).
Procedures:
1. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move;
2. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for siting on a side
of the bed;
3. Identify any movement limitations;
4. Perform hand hygiene and put on PPE, if indicated;
5. Identify the patient;
6. Introduce yourself;
7. Explain procedure to patient to gain consent;
8. Provide for client privacy;
9. Position the equipment appropriately:
10. Lower the bed to its lowest position so that the client’s feet will rest flat on the floor. Lock the
wheels of the bed;
11. Place the wheelchair parallel to the bed and as close to the bed as possible. Put the wheelchair
on the side of the bed that allows the client to move toward his or her stronger side. Lock the
wheels of the wheelchair, raise the footplates, and move the leg rests out of the way;

Figure 1 - Positioning the wheelchair appropriately

Font: Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
12. Prepare and assess the client:

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 13. Assist the client to a sitting position on the side of the bed;
14. Assess the client for orthostatic hypotension before moving the client from the bed;
15. Assist the client in putting on a bathrobe and nonskid slippers or shoes;
16. Place a gait or transfer belt snugly around the client’s waist. Check to be certain that the belt is
securely fastened;
17. Give explicit instructions to the client. Ask the client to:
18. Move forward and sit on the edge of the bed (or surface on which the client is sitting) with feet
placed flat on the floor;
19. Lean forward slightly from the hips;
20. Place the foot of the stronger leg beneath the edge of the bed (or sitting surface) and put the
other foot forward;
21. Place the client’s hands on the bed surface (or available stable area) so that the client can push
while standing;
22. Position yourself correctly:
23. Stand directly in front of the client and to the side requiring the most support;
24. Hold the gait or transfer belt with the nearest hand; the other hand supports the back of the
client’s shoulder;
25. Lean your trunk forward from the hips;
26. Flex your hips, knees, and ankles;
27. Assume a broad stance, placing one foot forward and one back;
28. 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;
29. Assist the client to stand, and then move together toward the wheelchair or sitting area to which
you wish to transfer the client:
30. On the count of three or the verbal instructions of “Ready–steady–stand” and on the count of
three or the word “Stand,” ask the client to push down against the mattress or 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 (directly toward your center of gravity) into a standing
position. (If the client requires more than a very small degree of pulling, even with the assistance
of two nurses, a mechanical device should be obtained and used);
31. Support the client in an upright standing position for a few moments;
32. Together, pivot on your foot farthest from the chair, or take a few steps toward the wheelchair,
bed, chair, commode, or car seat;
33. Assist the client to sit:
34. Move the wheelchair forward or have the client back up to the wheelchair (or desired seating
area) and place the legs against the seat;
35. Make sure the wheelchair brakes are on;
36. Have the client reach back and feel or hold the arms of the wheelchair;
37. Stand directly in front of the client. Place one foot forward and one back;
38. Tighten your grasp on the gait or transfer belt, and tighten your gluteal, abdominal, leg, and arm
muscles;
39. Have the client sit down while you bend your knees and hips and lower the client onto the
wheelchair seat;
40. Ensure client safety:
41. Ask the client to push back into the wheelchair seat;
42. Remove the gait or transfer belt;
43. Lower the leg rests and footplates, and place the client’s feet on them, if applicable.

Variation: Transferring with a Belt and Two Nurses:

Even if a client is able to partially bear weight and is cooperative, it still may be safer to transfer a client
with the assistance of two nurses. If so:
44. Position yourselves on both sides of the client, facing the same direction as the client;
45. Flex your hips, knees, and ankles;
46. Grasp the client’s transfer belt with the hand closest to the client, and with the other hand

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 support the client’s elbows:
47. Coordinating your efforts, all three of you stand simultaneously, pivot, and move to the
wheelchair. Reverse the process to lower the client onto the wheelchair seat.

Variation: Transferring a Client with an Injured Lower Extremity

When the client has an injured lower extremity, movement should always occur toward the client’s
unaffected (strong) side. For example, if the client’s right leg is injured and the client is sitting on the edge
of the bed preparing to transfer to a wheelchair, position the wheelchair on the client’s left side.

Variation: Using a Slide Board

For clients who cannot stand but are able to cooperate and possess sufficient upper body strength, use a
slide board to help them move without nursing assistance.

Figure 1 - Using a slide board

Font: Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.

48. Document relevant information:

• Client’s ability to bear weight and pivot
• Number of staff needed for transfer and the safety measures and precautions used
• Length of time up in chair
• Client response to transfer and being up in chair or wheelchair.

Transferring Between Bed and Stretcher:

Preparation:
49. Obtain the necessary equipment and nursing personnel to assist in the transfer;
50. Note any devices attached to the client.

Procedures:
51. Review the medical record and nursing plan of care for conditions that may influence the
patient’s ability to move;
52. Assess for tubes, IV lines, incisions, or equipment that may alter the procedure for siting on a side
of the bed;
53. Identify any movement limitations;
54. Perform hand hygiene and put on PPE, if indicated;
55. Identify the patient;
56. Introduce yourself;
57. Explain procedure to patient to gain consent;
58. Provide for client privacy;
59. Adjust the client’s bed in preparation for the transfer:
 Lower the head of the bed until it is flat or as low as the client can tolerate;
 Place the friction-reducing device under the client;

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  Raise the bed so that it is slightly higher (i.e., 1/2 in.) than the surface of the stretcher;
 Ensure that the wheels on the bed are locked;
 Place the stretcher parallel to the bed next to the client and lock the stretcher wheels;
 Fill the gap that exists between the bed and the stretcher loosely with the bath blankets
(optional);
60. Transfer the client securely to the stretcher:
 If the client can transfer independently, encourage him or her to do so and stand by for
safety;
 If the client is partially able or not able to transfer:
 One caregiver needs to be at the side of the client’s bed, between the client’s shoulder
and hip;
 The second and third caregivers should be at the side of the stretcher: one positioned
between the client’s shoulder and hip and the other between the client’s hip and lower
legs;
 All caregivers should position their feet in a walking stance;
 Ask the client to flex the neck during the move, if possible, and place the arms across the
chest;
 On a planned command, the caregivers at the stretcher’s side pull (shifting weight to the
rear foot), and the caregiver at the bedside pushes the client toward the stretcher (shifting
weight to the front foot);
61. Ensure client comfort and safety:
 Make the client comfortable, unlock the stretcher wheels, and move the stretcher away from
the bed;
 Immediately raise the stretcher side rails or fasten the safety straps across the client.
Rationale: Because the stretcher is high and narrow, the client is in danger of falling unless
these safety precautions are taken.

Variation: Using a Transfer Board:

The transfer board is a lacquered or smooth polyethylene board measuring 45 to 55 cm (18 to 22 in.) by
182 cm (72 in.) with handholds along its edges. Transfer mattresses are also available, as are mechanical
assistive devices.
It is imperative to have enough staff assisting with the transfer to prevent injury to staff as well as clients.
Turn the client to a lateral position away from you, position the board close to the client’s back, and roll
the client onto the board.
Pull the client and board across the bed to the stretcher. Safety belts may be placed over the chest,
abdomen, and legs.
62. Remove gloves and any other PPE, if used;
63. Perform hand hygiene;
64. Document relevant information:
 Equipment used;
 Number of personnel needed for transfer and safety measures and precautions used;
 Destination if reason for transfer is to transport from one location to another.
Nursing registry
Date and Time: Transferred the client between bed and chair. The client J.S. was able to bear his weight
during the transfer, but had difficulty pivoting. Two staff members were needed for the transfer. A safety
belt and support bars were used to ensure the client's safety during the procedure. The client remained
in the chair for 20 minutes. The client reported feeling some pain in the lower back, but felt secure in the
chair. A pillow was offered to help alleviate the pain. Name of the professional, position, and Guyana
Nursing Registration.

Date and Time: Transferred Mr. J. S. between bed and stretcher. Sheets were used to transfer the client
and a safety belt was used to ensure safety during the procedure. Two staff members were needed for
the transfer. A safety belt was used and the client was held by the ends of the sheet to ensure safety
during the procedure. The patient's destination is the examination room for imaging exams. Name of the

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professional, position, and Guyana Nursing Registration.
References
1. Bergman R, De Jesus O. Patient Care Transfer Techniques. [Updated 2022 Oct 17]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
[Link]
2. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
3. Lynn P. Taylor's Handbook of Clinical Nursing Skills. 1st ed. Philadelphia: Wolters Kluwer; 2011.
990 p.
4. Smith-Temple J, Johnson JY. Nurses’ guide to clinical procedures. 6th ed. Philadelphia: Walters
Kluwer & Lippincott Williams & Wilkins; 2010. 966 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

6/2
 Attachment E7:
BED POSITIONS: FOWLER’S AND ORTHOPNEIC
Related Course(s) Clinical skills
Theoretical content Bed positions
Definition Patient positioning involves properly maintaining a patient’s neutral body
alignment by preventing hyperextension and extreme lateral rotation to prevent
complications of immobility and injury.
Rationale  To provide patient comfort and safety.
 Maintaining patient dignity and privacy.
 Allows maximum visibility and access
Principles  Patients with impaired nervous or musculoskeletal system functioning,
patients with increased weakness, and patients restricted to bed rest
benefit from therapeutic positioning.
 Correct positioning maintains patients’ body alignment and comfort.
 Immobilized patients require vigilant nursing care with frequent
repositioning to avoid physical complications, including pressure injuries,
reduced ventilation, and muscle contractures.
Requisities  Pillows, drawsheet
 Appropriate safe patient handling assistive devices (e.g., friction reducing
device, ceiling lift, or mechanical floor lift)
 Therapeutic boots/splints (optional)
 Trochanter rolls (optional)
 Hand rolls
 Clean gloves
Assessment:
1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical
record number) according to agency policy.
2. Refer to medical record for most recent recorded weight and height for patient.
3. Check health care provider's orders for any restrictions in movement before positioning
patient.
4. Assess patient's range of motion (ROM) and current body alignment while patient is lying
down.
5. Assess for risk factors that contribute to complications of immobility:
 Reduced sensation: Cerebrovascular accident (CVA), spinal cord injury, or neuropathy.
Rationale: With reduced sensation, a patient has difficulty moving, has poor awareness of
involved body part, and is unable to position body part and protect it from pressure.
 Impaired mobility: Traction, arthritis, CVA, spinal cord injury, hip fracture, joint surgery, or
other contributing disease processes.
 Impaired circulation: Arterial insufficiency.
 Age: Very young, older adult.
6. Assess patient's level of consciousness.
7. Assess patient for presence of pain; rate on scale of 0 to 10.
8. Assess condition of patient's skin, especially over bony prominences.
9. Assess patient's physical ability to help with moving and positioning, which may be affected
by age, level of consciousness, disease process, strength, ROM, and coordination.
10. Assess patient's vision and hearing.
11. Apply clean gloves (as needed) to assess for presence of incisions, drainage tubes, and
equipment (e.g., traction). Empty drainage bags before positioning. Remove and dispose of
gloves. Perform hand hygiene.
12. Assess motivation of patient and ability of family caregivers to participate in moving and
positioning if patient to be discharged home.
13. Assess patient's or family caregiver's knowledge, experience, and health literacy.

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Planning
1. Expected outcomes following completion of procedure:
 Patient retains ROM.
 Patient's skin shows no evidence of breakdown.
 Patient's comfort level increases.
 Patient's level of independence in completing activities of daily living increases.
2. If patient perceives level of pain to be enough to avoid movement, offer an analgesic 30 minutes
(if ordered) before repositioning.
3. Remove all pillows and devices used in previous position.
4. Get additional caregivers and/or necessary lift or transfer device to perform positioning.
5. Explain positioning procedure to patient using plain language.
6. Close door to room or bedside curtains.
Procedures:
1. Perform hand hygiene.
2. Raise level of bed to comfortable working height, level with your elbows.
3. Assist patient to move up in bed:
a) Determine if the patient can assist.
 Patient is fully able to assist:
 Stand at bedside to help with positioning of tubing and equipment as patient moves.
 Have patient place feet flat on mattress, grasp either side rails or overhead trapeze
and, on a count of three, lift hips up and push legs so body moves up in bed.

 Patient is partially able to assist:

 Encourage patient to help using friction-reducing device (e.g., slide board).
 Patient weighs less than 91 kg (200 lb): use friction-reducing sheet or slide board
and two or three caregivers.
 Patient weighs greater than 91 kg (200 lb): use friction-reducing device and at least
three caregivers.
i. Using a friction-reducing device (three nurses). Position patient supine with
head of bed flat. A nurse stands on each side of bed.
ii. Remove pillow from under head and shoulders and place it at head of bed.
iii. Turn patient side to side to place friction-reducing device under drawsheet on
bed, with device extending from shoulders to thighs/ankles.
iv. Return patient to supine position.
v. Have two caregivers grasp drawsheet (one on each side of bed) firmly and
have third nurse hold on to end of friction-reducing device.
vi. Place feet apart with forward-backward stance. Flex knees and hips. On count
of three, shift weight from front to back leg and move patient and drawsheet
to desired position up in bed.

 Patient unable to assist:

 Use appropriate number of caregivers and appropriate safe patient-handling devices
(e.g., supine sling with ceiling lift or floor-based lift and two or more caregivers) to
move and position patient.

4. Position patient in bed in one of the following positions while ensuring correct body alignment.
5. Protect pressure areas:
a) Determine if patient can assist.
b) Begin with patient lying supine and move up in bed.
c) Position patient in supported semi-Fowler's or Fowler's position:

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 Figure 1 - A= Semi-Fowler’s position. B= Fowler’s position.
Font: Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.

6. With patient lying supine, elevate head of bed 45 to 60 degrees if not contraindicated.
7. Rest head against mattress or on small pillow.
8. Use pillows to support arms and hands if patient does not have voluntary control or use of hands
and arms.
9. Position small pillow at lower back.
10. Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion
(avoids hyperextension) and to allow the heels to float:
a) Position hemiplegic patient in supported semi-Fowler's or Fowler's position:
 Elevate head of bed 30 to 60 degrees according to patient's condition. For example,
those with increased risk for pressure injury remain at 30-degree angle.
 Position patient in Fowler's position as anatomically straight as possible.
 Position head on small pillow with chin slightly forward. If patient is totally unable to
control head movement, avoid hyperextension of neck.
 Provide support for involved arm and hand by placing arm away from patient's side and
supporting elbow with pillow.
 Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help
prevent the patient from leaning toward the affected side.
 Support feet in dorsiflexion with therapeutic boots or splints.
11. Be sure patient feels comfortable in new position. Be sure nurse call system is accessible within
patient's reach
12. Raise side rails (as appropriate) and lower bed to lowest position
13. Perform hand hygiene.
14. Assess patient's respiratory status, body alignment, position, and level of comfort. Patient's body
should be supported by adequate mattress, and vertebral column should be without observable
curves.
15. Document assessment findings, care given, and outcomes in the legal healthcare record.
a) Orthopneic position: In the orthopneic position, the client sits either in bed or on the side of
the bed with an overbed table across the lap. This position facilitates respiration by allowing
maximum chest expansion. It is particularly helpful to clients who have problems exhaling,
because they can press the lower part of the chest against the edge of the overbed table.

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 Figure 1 - Orthopneic position
Font: Berman, A., S. Snyder, and G. Frandsen, Kozier & Erb's Fundamentals of Nursing: concepts, process
and practice. 11th ed. 2022, United Kingdom: British Library. 1553 p.
Nursing documentation
Date and Time: Performed Fowler's position on Mr. J. S. to improve his ventilation and facilitate
expectoration. The procedure was carried out with the assistance of a nursing assistant, ensuring the
patient's safety throughout the process. An adjustable bed with height and headrest angle settings was
used, along with a pillow positioned appropriately to support the patient's head and trunk, and safety
measures were implemented. The bed height was checked to prevent falls or discomfort for the patient,
and it was ensured that the side rails were properly elevated and locked. The bed stability was ensured
before adjusting the headrest position, and the patient was carefully positioned, avoiding abrupt
movements and injuries. The patient reported improved respiratory comfort after the establishment of
the Fowler's position. There was observed improvement in peripheral oxygenation, with oxygen
saturation increasing from 92% to 96% after the change in position. The patient showed relief from
dyspnea and facilitation of expectoration of pulmonary secretions. The benefits of Fowler's position were
explained to the patient, and they were encouraged to communicate any discomfort or changes in their
breathing. Name of the professional, position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Lynn P. Taylor's Handbook of Clinical Nursing Skills. 1st ed. Philadelphia: Wolters Kluwer; 2011.
990 p.
3. Perry AGP, Potter PA, Ostendorf WR. Nursing interventions & clinical skills. 7th ed. St Louis:
Elsevier; 2020. 2196 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

4/2
 Attachment E8:
BED POSITIONS: DORSAL RECUMBENT AND SUPINE/DORSAL
Related Course(s) Clinical skills
Theoretical content Moving
Positioning
Lifting and turning patients
Definition The procedures involved to position the patient correctly and maintain body
alignment and comfort. Immobilized patients require vigilant nursing care with
frequent repositioning to avoid physical complications, including pressure
injuries, reduced ventilation, and muscle contractures.
Rationale  To position a patient in bed in order to maintain alignment and prevent
pressure injuries, foot drop, and contractures.
Principles  Positioning a patient in bed is important for maintaining alignment and
for preventing pressure injury, foot drop, and contractures.
 Proper positioning is also vital for providing comfort for patients who are
bedridden or have decreased mobility related to a medical condition or
treatment.
 When positioning a patient in bed, supportive devices such as pillows,
rolls, and blankets, along with repositioning, can aid in providing comfort
and safety.
Requisities  Pillows, drawsheet
 Appropriate safe patient handling assistive devices (e.g., friction reducing
device, ceiling lift, or mechanical floor lift)
 Therapeutic boots/splints (optional)
 Trochanter rolls (optional)
 Hand rolls
 Clean gloves
Assessment:
 Identify patient using at least two identifiers (e.g., name and birthday or name and medical
record number) according to hospital policy.
 Refer to medical record for most recent recorded weight and height for patient. This information
helps to determine if mechanical lift, mechanical transfer device, or friction-reducing device is
needed for moving patient up in bed.
 Check health care provider's orders for any restrictions in movement before positioning patient.
Some positions may be contraindicated in situations such as spinal cord injury; hip fracture;
respiratory difficulties; neurological conditions; and presence of incisions, drains, or tubing.
 Perform hand hygiene.
 Assess patient's range of motion (ROM) and current body alignment while patient is lying down.
This procedure provides baseline data for later comparisons. Determines ways to improve
position and alignment.
 Assess for risk factors that contribute to complications of immobility. Risk factors require patient
to be repositioned more frequently.
 Reduced sensation: Cerebrovascular accident (CVA), spinal cord injury, or neuropathy. With
reduced sensation, a patient has difficulty moving, has poor awareness of involved body part,
and is unable to position body part and protect it from pressure.
 Impaired mobility: Traction, arthritis, CVA, spinal cord injury, hip fracture, joint surgery, or
other contributing disease processes. Traction, bone fractures, surgery, or arthritic changes
result in decreased ROM. Loss of function caused by CVA or spinal injury can lead to
contractures.
 Impaired circulation: Arterial insufficiency. Decreased circulation predisposes patient to
pressure injury.
 Age: Very young, older adult. Premature and young infants require frequent turning
because their skin is fragile. Normal physiological changes of aging predispose to greater

1/2
 risks for developing complications of immobility.
 Assess patient's level of consciousness. Determines need for special aids or devices. Patients with
altered levels of consciousness may not understand instructions and may be unable to help with
positioning.
 Assess patient for presence of pain; rate on scale of 0 to 10. Pain reduces patient's motivation
and ability to be mobile. Pain relief before transfer enhances patient participation.
 Assess condition of patient's skin, especially over bony prominences. Provides baseline to
determine effects of positioning. Routine positioning reduces occurrence of pressure injuries.
 Assess patient's physical ability to help with moving and positioning, which may be affected by
age, level of consciousness, disease process, strength, ROM, and coordination.
 Assess patient's vision and hearing.
 Apply clean gloves (as needed) to assess for presence of incisions, drainage tubes, and
equipment (e.g., traction).
 Empty drainage bags before positioning.
 Assess motivation of patient and ability of family caregivers to participate in moving and
positioning if patient to be discharged home.
 Assess patient's or family caregiver's knowledge, experience, and health literacy.

Planning
 Expected outcomes following completion of procedure:
 Patient retains ROM.
 Patient's skin shows no evidence of breakdown.
 Patient's comfort level increases.
 Patient's level of independence in completing activities of daily living increases.
 If patient perceives level of pain to be enough to avoid movement, offer an analgesic 30 minutes
(if ordered) before repositioning.
 Remove all pillows and devices used in previous position.
 Get additional caregivers and/or necessary lift or transfer device to perform positioning.
 Explain positioning procedure to patient using plain language.
 Close door to room or bedside curtains.
Procedures:
1. Perform hand hygiene;
2. Raise level of bed to comfortable working height, level with your elbows;
3. Assist patient to move up in bed:
 Determine if the patient can assist:
a) Patient is fully able to assist:
 Stand at bedside to help with positioning of tubing and equipment as patient moves;
 Have patient place feet flat on mattress, grasp either side rails or overhead trapeze
and, on a count of three, lift hips up and push legs so body moves up in bed.

b) Patient is partially able to assist:

 Encourage patient to help using friction-reducing device (e.g., slide board)
 Patient weighs less than 91 kg (200 lb): use friction-reducing sheet or slide board and
two or three caregivers.
 Patient weighs greater than 91 kg (200 lb): use friction-reducing device and at least
three caregivers.
i. Using a friction-reducing device (three nurses). Position patient supine with
head of bed flat. A nurse stands on each side of bed.
ii. Remove pillow from under head and shoulders and place it at head of bed.
iii. Turn patient side to side to place friction-reducing device under drawsheet on
bed, with device extending from shoulders to thighs/ankles.
iv. Return patient to supine position.
v. Have two caregivers grasp drawsheet (one on each side of bed) firmly and have
third nurse hold on to end of friction-reducing device.

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 vi. Place feet apart with forward-backward stance. Flex knees and hips. On count
of three, shift weight from front to back leg and move patient and drawsheet to
desired position up in bed.

c) Patient unable to assist:

 Use appropriate number of caregivers and appropriate safe patient-handling devices
(e.g., supine sling with ceiling lift or floor-based lift and two or more caregivers) to
move and position patient
4. Position patient in bed in one of the following positions while ensuring correct body
alignment;
5. Protect pressure areas:
 Determine if patient can assist.
 Begin with patient lying supine and move up in bed following Steps 3.
 Position patient in supported supine position:
a) Place patient supine with head of bed flat.
b) Place small rolled towel under lumbar area of back.
c) Place pillow under upper shoulders, neck, and head.
d) Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs.
e) Place patient's feet in therapeutic boots or splints.
f) Place pillows under pronated forearms, keeping upper arms parallel to patient's body.

Figure 1 - Positioning patient in bed to ensure correct body alignment

Source: Perry, A.G.P., P.A. Potter, and W.R. Ostendorf, Nursing interventions & clinical skills. 7th ed.
2020, St Louis: Elsevier. 2196 p.

6. Place hand rolls in patient's hands. Consider physical therapy referral for use of hand splints;
7. Be sure patient feels comfortable in new position;
8. Be sure nurse call system is accessible within patient's reach;
9. Raise side rails (as appropriate) and lower bed to lowest position;
10. Perform hand hygiene;
11. Assess patient's respiratory status, body alignment, position, and level of comfort. Patient's body
should be supported by adequate mattress, and vertebral column should be without observable
curves.

d. Dorsal recumbent position: In the dorsal recumbent(back-lying) position, the client’s head
and shoulders are slightly elevated on a small pillow. In some agencies, the terms dorsal
recumbent and supine are used interchangeably; strictly speaking, however, in the supine or
dorsal position the head and shoulders are not elevated. In both positions, the client’s
forearms may be elevated on pillows or placed at the client’s sides. Supports are similar in
both positions, except for the head pillow. The dorsal recumbent position is used to provide
comfort and to facilitate healing following certain surgeries or anesthetics (e.g., spinal).

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 Figure 2 - Dorsal recumbent position
Font: Berman, A., S. Snyder, and G. Frandsen, Kozier & Erb's Fundamentals of Nursing: concepts, process
and practice. 11th ed. 2022, United Kingdom: British Library. 1553 p.

12. Remove gloves and any other PPE, if used;

13. Perform hand hygiene;
14. Document the care provided.
Nursing Documentation
Date and Time: Performed Dorsal recumbent position on Mr. J.S. with the assistance of two nursing
technicians. We used a cervical pillow, positioning cushion, and sheets. The bed's stability was checked
before positioning the patient. The patient was placed in a dorsal recumbent position, with the head
supported by the cervical pillow and the legs elevated with the assistance of the positioning cushion.
During the position, the patient experienced mild abdominal discomfort, which was monitored and
reported to the medical team for further evaluation. The patient mentioned mild respiratory difficulty
after the position change, promptly assessed and monitored. Erythema was observed in the sacral
region, and appropriate pressure redistribution was performed to prevent pressure ulcers. The patient
was instructed about the importance of the position and encouraged to report any additional discomfort.
Name of the professional, position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Lynn P. Taylor's Handbook of Clinical Nursing Skills. 1st ed. Philadelphia: Wolters Kluwer; 2011.
990 p.
3. Smith-Temple J, Johnson JY. Nurses’ guide to clinical procedures. 6th ed. Philadelphia: Walters
Kluwer & Lippincott Williams & Wilkins; 2010. 966 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

4/2
 Attachment E9:
BED POSITIONS: SIM’S
Related Course(s) Health assessment
Nursing process
Theoretical content Bed positions
Definition Sims’ position or semi-prone position is when the patient assumes a posture
halfway between the lateral and the prone positions. The lower arm is positioned
behind the client, and the upper arm is flexed at the shoulder and the elbow. The
upper leg is more acutely flexed at both the hip and the knee than is the lower
one.
Rationale  To prevents aspiration of fluids. Sims’ may be used for unconscious
clients because it facilitates drainage from the mouth and prevents
aspiration of fluids.
 To reduce lower body pressure. It is also used for paralyzed clients
because it reduces pressure over the sacrum and greater trochanter of
the hip.
 To promote perineal area visualization and treatment. It is often used for
clients receiving enemas and occasionally for clients undergoing
examinations or treatments of the perineal area.
 To provide pregnant women comfort. Pregnant women may find the Sims
position comfortable for sleeping.
 To promote body alignment with pillows.
Principles  Patients with impaired nervous or musculoskeletal system functioning,
patients with increased weakness, and patients restricted to bed rest
benefit from therapeutic positioning.
 Correct positioning maintains patients’ body alignment and comfort.
 Immobilized patients require vigilant nursing care with frequent
repositioning to avoid physical complications, including pressure injuries,
reduced ventilation, and muscle contractures.
Requisities  Pillows, drawsheet
 Appropriate safe patient handling assistive devices (e.g., friction reducing
device, ceiling lift, or mechanical floor lift)
 Therapeutic boots/splints (optional)
 Trochanter rolls (optional)
 Hand rolls
 Clean gloves
Assessment:
1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical
record number) according to agency policy.
2. Refer to medical record for most recent recorded weight and height for patient.
3. Check health care provider's orders for any restrictions in movement before positioning patient.
4. Perform hand hygiene.
5. Assess patient's range of motion (ROM) and current body alignment while patient is lying down.
6. Assess for risk factors that contribute to complications of immobility.
a) Reduced sensation: Cerebrovascular accident (CVA), spinal cord injury, or neuropathy.
b) Impaired mobility: Traction, arthritis, CVA, spinal cord injury, hip fracture, joint surgery, or
other contributing disease processes.
c) Impaired circulation: Arterial insufficiency.
d) Age: Very young, older adult.

7. Assess patient's level of consciousness. Rationale: Determines need for special aids or devices.
Patients with altered levels of consciousness may not understand instructions and may be unable
to help with positioning.

1/2
 8. Assess patient for presence of pain; rate on scale of 0 to 10. Rationale: Pain reduces patient's
motivation and ability to be mobile. Pain relief before transfer enhances patient participation.
9. Assess condition of patient's skin, especially over bony prominences. Rationale: Provides baseline
to determine effects of positioning. Routine positioning reduces occurrence of pressure injuries.
10. Assess patient's physical ability to help with moving and positioning, which may be affected by
age, level of consciousness, disease process, strength, ROM, and coordination. Rationale: Enables
you to use patient's existing mobility, strength, and coordination during positioning. Determines
need for additional help, ensuring patient and nurse safety.
11. Assess patient's vision and hearing. Rationale: Sensory deficits affect patient's ability to
cooperate during repositioning.
12. Apply clean gloves (as needed) to assess for presence of incisions, drainage tubes, and
equipment (e.g., traction). Empty drainage bags before positioning. Remove and dispose of
gloves. Perform hand hygiene. Rationale: Alters positioning procedure and type of position in
which to place patient. Eliminates barriers to moving patient.
13. Assess motivation of patient and ability of family caregivers to participate in moving and
positioning if patient to be discharged home. Rationale: Indicates level of instruction needed
before discharge.
14. Assess patient's or family caregiver's knowledge, experience, and health literacy. Rationale:
Ensures patient or family caregiver has the capacity to obtain, communicate, process, and
understand basic health information.

Planning:
1. Expected outcomes following completion of procedure:
 Patient retains ROM.
 Patient's skin shows no evidence of breakdown.
 Patient's comfort level increases.
 Patient's level of independence in completing activities of daily living increases.
2. If patient perceives level of pain to be enough to avoid movement, offer an analgesic 30 minutes
(if ordered) before repositioning.
3. Remove all pillows and devices used in previous position.
4. Get additional caregivers and/or necessary lift or transfer device to perform positioning.
5. Explain positioning procedure to patient using plain language.
6. Close door to room or bedside curtains.
Procedures:
1. Perform hand hygiene.
2. Raise level of bed to comfortable working height, level with your elbows.
3. Assist patient to move up in bed:
a) Determine if the patient can assist.
 Patient is fully able to assist:
 Stand at bedside to help with positioning of tubing and equipment as patient moves.
 Have patient place feet flat on mattress, grasp either side rails or overhead trapeze
and, on a count of three, lift hips up and push legs so body moves up in bed.

b) Patient is partially able to assist:

 Encourage patient to help using friction-reducing device (e.g., slide board).
 Patient weighs less than 91 kg (200 lb): use friction-reducing sheet or slide board and two
or three caregivers.
 Patient weighs greater than 91 kg (200 lb): use friction-reducing device and at least three
caregivers.
 Using a friction-reducing device (three nurses). Position patient supine with head of
bed flat. A nurse stands on each side of bed.
 Remove pillow from under head and shoulders and place it at head of bed.
 Turn patient side to side to place friction-reducing device under drawsheet on bed,
with device extending from shoulders to thighs/ankles.

2/2
  Return patient to supine position.
 Have two caregivers grasp drawsheet (one on each side of bed) firmly and have third
nurse hold on to end of friction-reducing device.
 Place feet apart with forward-backward stance. Flex knees and hips. On count of
three, shift weight from front to back leg and move patient and drawsheet to desired
position up in bed.

c) Patient unable to assist:

 Use appropriate number of caregivers and appropriate safe patient-handling devices
(e.g., supine sling with ceiling lift or floor-based lift and two or more caregivers) to move
and position patient.

4. Position patient in bed in one of the following positions while ensuring correct body
alignment.
5. Protect pressure areas.
a) Determine if patient can assist.
b) Begin with patient lying supine and move up in bed.
c) Position patient in the Sims’ (semi-prone) position:
 Lower head of bed completely.
 Place patient supine on side of bed opposite direction toward which he or she is to be
turned. Move upper trunk, supporting shoulders first, followed by moving lower trunk,
supporting hips.
 Move to other side of bed and turn patient on side. Position in lateral position, lying
partially on abdomen, with dependent shoulder lifted out and arm placed at patient's
side.
 Place small pillow under patient's head.
 Place pillow under flexed upper arm, supporting arm level with shoulder.
 Place pillow under flexed upper legs, supporting leg level with hip.
 Place sandbags parallel against plantar surface of foot.

Figure 1 - Sims’ (semi-prone) position

Font: Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.

6. Remove friction-reducing surface, if used.

7. Provide comfort. Assist the client with positioning, replace the pillows, and rearrange
bedding.
8. Secure all medical equipment attached to the client and check for patency, such as
intravenous lines and Foley catheters. Equipment can become kinked or disconnected with
client movement.
9. Ensure client safety. Place bed in the lowest position and verify that the client can identify
and reach the nurse call system. These safety measures reduce the risk of falls.
10. Evaluate outcomes. Your evaluation includes how the client tolerated the procedure and the
amount of assistance the client required to reposition.

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 11. Remove gloves, if used.
12. Perform hand hygiene.
13. Document assessment findings, care given, and outcomes in the legal healthcare record.
Nursing documentation:
Date and Time: The Sims' position was performed on Mr. J. S. with the aim of facilitating the proper
exposure of the anal region for the fleet enema procedure. Ensured that the patient was comfortable
and stable in the Sims' position. Checked for sufficient support cushions to prevent pressure points and
injuries. Maintained constant communication with the patient during the procedure to ensure their well-
being. During the Sims' position, the patient reported some initial discomfort, which was alleviated after
making adjustments to the position. The patient's breathing was regular, and there were no signs of
respiratory difficulties. No significant changes in vital signs were observed during the procedure;
however, it was noted that the patient had sensitive skin in the anal region, which may require special
attention in the future. Name of the professional, position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Perry AGP, Potter PA, Ostendorf WR. Nursing interventions & clinical skills. 7th ed. St Louis:
Elsevier; 2020. 2196 p.
3. 3. Stein LNM, Hollen CJ. Concept-based clinical nursing skills: fundamentals to advanced. St Louis:
Elsevier; 2021. 2776 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

4/2
 Attachment E10:
BED POSITIONS: TRENDELENBURG AND REVERSE
TRENDELENBURG
Related Course(s) Health assessment
Nursing process
Theoretical content Bed positions
Definition Trendelenburg’s position involves lowering the head of the bed and raising the
foot of the bed of the patient. The patient’s arms should be tucked at their sides.
Rationale  To promote venous return.
 To promote postural drainage.
Principles  Trendelenburg’s position: To promote venous circulation in certain
clients. To provide postural drainage of basal lung lobes.
 Reverse Trendelenburg’s position: To promote stomach emptying and
prevent esophageal reflux in client with hiatal hernia.
Requisities  Adjustable bed
 Pillows or cushions
 Safety belts
 Foot support
Procedures:
Trendelenburg’s position:

1. Check the medical order: Ensure that there is a clear and up-to-date medical order to position
the patient in the Trendelenburg position.
2. Inform the patient: Explain to the patient the procedure that will be performed, the reasons for
positioning in the Trendelenburg position, and obtain their consent.
3. Prepare the environment: Ensure that the environment is safe, with adequate space around the
patient's bed to facilitate the movement of the nursing staff. Make sure that the necessary
materials are readily available.
4. Assess the patient's condition: Evaluate the patient's overall condition, including vital signs, level
of consciousness, and tolerance to position changes. If there are concerns, consult the medical
team before proceeding.
5. Position the bed: Adjust the hospital bed to the Trendelenburg position, with the head down and
the lower part of the bed elevated. Ensure that the bed locking mechanisms are properly
engaged to ensure safety.
6. Place safety belts: Position the safety belts over the patient, ensuring that they are snug but not
overly tight. Make sure that the belts pass over the appropriate areas of the body to avoid
discomfort or injuries.
7. Place pillows or cushions: Strategically position pillows or cushions to provide support to the
patient's body and ensure they remain stable and comfortable in the inclined position. Ensure
that the head and back are well supported.
8. Provide foot support: Place pillows or supports under the patient's feet to ensure they are
comfortable and prevent slipping.
9. Monitor the patient: Place the necessary monitoring equipment, such as a pulse oximeter,
cardiac monitor, and blood pressure monitor, in accessible locations to continuously monitor the
patient's vital signs.
10. Check comfort and safety: Verify that the patient is comfortable, free from excessive pain, and
well-positioned in bed. Ensure that the safety belts are properly adjusted but not restrictive, and
check that the patient has easy access to the nurse call button.
11. Document the procedure: Adequately record the procedure of positioning in the Trendelenburg
position, including the time, the exact position of the bed, the materials used, and any relevant
observations about the patient.

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 Figure 1 - Trendelenburg’s position
Font: [Link]

Reverse Trendelenburg’s position:

1. Check the medical order: Ensure that there is a clear and updated medical order to position the
patient in the reverse Trendelenburg position.
2. Inform the patient: Explain to the patient the procedure that will be performed, the reasons for
positioning in the reverse Trendelenburg position, and obtain their consent.
3. Prepare the environment: Ensure that the environment is safe, with adequate space around the
patient's bed to facilitate the movement of the nursing staff. Make sure that the necessary
materials are readily available.
4. Assess the patient's condition: Evaluate the patient's overall condition, including vital signs, level
of consciousness, and tolerance to position changes. If there are concerns, consult the medical
team before proceeding.
5. Position the bed: Adjust the hospital bed to the reverse Trendelenburg position, with the head
elevated and the lower part of the bed lowered. Ensure that the bed locking mechanisms are
properly engaged to ensure safety.
6. Place safety belts: Position the safety belts over the patient, ensuring that they are snug but not
overly tight. Make sure that the belts pass over the appropriate areas of the body to avoid
discomfort or injuries.
7. Place pillows or cushions: Strategically position pillows or cushions to provide support to the
patient's body and ensure they remain stable and comfortable in the inclined position. Ensure
that the head and back are well supported.
8. Provide foot support: Place pillows or supports under the patient's feet to ensure they are
comfortable and prevent slipping.
9. Monitor the patient: Place the necessary monitoring equipment, such as a pulse oximeter,
cardiac monitor, and blood pressure monitor, in accessible locations to continuously monitor the
patient's vital signs.
10. Check comfort and safety: Verify that the patient is comfortable, free from excessive pain, and
well-positioned in bed. Ensure that the safety belts are properly adjusted but not restrictive, and
check that the patient has easy access to the nurse call button.
11. Document the procedure: Adequately record the procedure of positioning in the reverse
Trendelenburg position, including the time, the exact position of the bed, the materials used, and
any relevant observations about the patient.

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 Figure 2 - Reverse Trendelenburg’s position
Font: [Link]
Nursing documentation
Date and Time: Performed positioning in the reverse Trendelenburg position for Mr. J. S. Patient's
condition assessed, including vital signs, level of consciousness, and tolerance to position changes. No
concerns identified. Bed positioned in the reverse Trendelenburg position, with elevated head and
lowered lower part of the bed. Bed locking mechanisms properly engaged. Safety belts positioned over
the patient, securely but not overly tight. Belts passing over appropriate areas of the body to prevent
discomfort or injuries. Pillows or cushions strategically positioned to provide support to the patient's
body. Head and back well supported. Pillows or supports placed under the patient's feet to provide
support and prevent slipping. Patient checked for comfort, absence of excessive pain, and proper
positioning in bed. Name of the professional, position, and Guyana Nursing Registration.
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Perry AGP, Potter PA, Ostendorf WR. Nursing interventions & clinical skills. 7th ed. St Louis:
Elsevier; 2020. 2196 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
May/2023

3/2
 Attachment F:
MAKING AN UNOCCUPIED BED, OCCUPIED BED
Related Course(s) Clinical skills
Theoretical content Bed Making and accessories
Definition Bed making is a necessary skill to keep the environment clean, prevent skin
breakdown and the spread of infection, and respect the resident’s dignity by
providing an orderly environment.
Rationale  To promote hygiene and comfort to the patient.
Principles  Never allow linens to touch your uniform.
 Do not transfer linens from one room to another.
 Do not place soiled linens on the floor.
 If linens touch the floor, they should be placed in the soiled laundry for
cleaning and not used.
 Do not shake linens because it can spread airborne pathogens.
 Store clean linens in a closed closet or a covered cart
Requisities  3 Sheets
 1 Pillowcase
 Clean gloves
 Chair
 Hamper
Procedures:
1. Sanitize your hands.
2. Gather the materials in the infirmary and place them on a chair seat next to the bed.
3. Place each bed linen to be used on the back of the chair in the following order:
a) Pillowcase - folded once across the middle.
b) Top sheet - folded twice lengthwise so that, when placed on the bed, the free edges are
facing up and towards the center of the mattress. The wider hem of the sheet should always
be at the head of the bed.
c) Fitted sheet - folded once across the middle and then twice lengthwise, with the wider hem
facing inward, so that when placed on the bed, the free edges are facing up and towards the
center of the mattress and the hems are facing the foot of the bed.
d) Bottom sheet - folded in the same way as the top sheet.
4. If necessary, put-on procedure gloves and change them during the procedure.
5. If possible, raise the patient's bed.
6. Lower the side rails and loosen all bedclothes.
7. Fold the bedclothes that do not need to be changed, such as sheets, blankets, and quilts, in four
and place them neatly on an empty chair.
8. Remove the bed linens in an orderly manner, one by one, starting with the top sheet, followed by
the fitted sheet and finally the bottom sheet.
9. As each piece of bed linen is removed, it should be placed in the hamper, kept away from the
body, and not placed on the floor or on furniture.
10. Perform concurrent cleaning of the patient's bed.
11. The professional should develop the entire technique on one side of the bed before moving to the
other side.
12. Start making the bed with the bottom sheet.
13. Place the central fold of the bottom sheet in the middle of the bed and enough to be folded under
the head of the mattress, stretching it rigorously to avoid wrinkles or folds that can cause
discomfort or skin lesions to the client.
14. The fitted sheet should be placed in the center of the bed, keeping the transverse fold.
15. After placing the bottom sheet and the fitted sheet, fold the bottom sheet under the head of the
mattress, forming a triangular fold with an approximate angle of 45 o. Repeat the procedure at the
foot of the bed. (If the sheet has elastic, there is no need to fold corners).

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 Figure 1 - Making an unoccupied bed, occupied bed
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16. Tuck the ends of the sheets under the mattress.

17. Repeat the same procedure on the other side of the bed.
18. Place the top sheet with the central fold in the middle of the bed and enough to be folded under
the foot of the mattress, forming the triangular fold at the corners.
19. Do not fold the side edges of the top sheet under the mattress, which should remain free.
20. Move to the other side of the bed and repeat the procedure.
21. After making both sides of the bed, fold 15 cm of the top edge of the top sheet.
22. If quilts or blankets are used, place them on the top sheet and then angle the corners. In addition,
the top edges of quilts or blankets should be placed about 15 cm below the top of the top sheet.
23. Fold the 15 cm top of the top sheet over the quilt or blanket.
24. Make a "comfort fold" in the top sheet to accommodate the patient's feet - make a 15 cm
transverse fold at the bottom edge of the top sheet.
25. Place the pillow on the headboard of the bed with the open end facing the window.
26. If the bed height has been adjusted for cleaning, readjust it to its usual position.
27. Position the call bell near the pillow.
28. Recompose the unit and send the hamper to the discard area.
29. Remove gloves and discard them in the trash.
30. Sanitize your hands.

Observations:
 A bed is considered closed when it is unoccupied, and the bed-making should follow all the
described steps.
 A bed is considered open when it is occupied by a patient who is able to ambulate, and the bed-
making should follow the described steps; however, there is a difference in the placement of the
top sheet: after folding the upper end of the top sheet, you should grab the end of the side facing
the door and bring it to the opposite side of the bed, making an envelope fold.
 If the patient is bedridden, the bed-making occurs with the patient in the bed and should be
performed by at least 2 professionals. The patient should be placed in a left lateral decubitus
position for making the right side of the bed and in a right lateral decubitus position for making
the left side of the bed. Also, since the top sheet is placed over the patient, it is not necessary to
make a foot fold for comfort.
 If the patient is in the surgical center, the top sheet should be placed on the bed as follows:
 Open it without securing it to the feet of the bed;
 Make a fold at the head and foot so that they meet at the center of the bed;
 Then, make accordion folds longitudinally toward the opposite side of the client's entrance,
keeping the center of the bed and the side where the patient will be received free.

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 Figure 2 - Surgical Bed
Font: [Link]
Nursing documentation
Not applicable
References
1. Berman A, Snyder S, Frandsen G. Kozier & Erb's Fundamentals of Nursing: concepts, process and
practice. 11th ed. United Kingdom: British Library; 2022. 1553 p.
2. Potter PA, Perry AGP, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. St Louis: Elsevier;
2021.
3. Lynn P. Taylor's Clinical Nursing Skills: a nursing process approach. 5ª ed. Philadelphia: Wolters
Kluwer; 2019. 3830 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023

3/2
 Attachment G:
VITAL SIGNS
Related Course(s) Health assessment
Theoretical content Vital signs
Definition These are the manifestations that reflect the physiological state of vital body
organs (brain, heart, lungs) that are necessary for sustaining life.
Rationale  To assist in making clinical appraisal of a patient’s condition on admission
and in ward monitoring.
 To determine the baseline for future comparisons.
 To detect as early as possible any deviation in the patient’s condition.
 To communicate with members of the health team any observations related
to the patient’s wellbeing.
Principles  People are less fearful and more cooperative when they know what to
expect.
 The range in body temperature in which the body cells can function
efficiently is 35.5–37.5 °C (96–99.5 °F) per axillae.
 The amount of knowledge a patient requires, depends upon the
individual’s circumstances, e.g., age, level of intelligence, health status etc.
 Body cells vary in their ability to withstand the extremities of temperature.
 Body temperature is controlled by regulation of the rate at which the
tissues produce heat and the rate at which heat is lost from the body.
 The amount of heat produced by the body can be decreased to prevent
overheating by:
 Decreasing cellular metabolic activity
 Increasing circulatory activity to the skin
 Decreasing muscle activity
 Increasing perspiration and respiration
 The greater the force and volume of blood into the arteries by ventricular
contraction, the greater will be the blood pressure
 Postural changes affect the arterial blood pressure. The pressure increases
immediately when changing from lying to sitting or standing.
 Physical activity causes a rise in blood pressure.
 The emotional state of an individual influences the blood pressure.
 Excess weight raises the blood pressure through the resulting increase in
blood capillaries which in turn places more work on the heart.
 Oxygen in adequate amounts is an element essential to maintaining the
oxidative reactions in cells for the production of energy.
 Rhythmic respiration is regulated by centers in the medulla oblongata and
carbon levels in the blood.
 Rise and fall of the anterior chest wall is an indication that the patient is
breathing.
Requisities  Clinical thermometer
 Container with alcohol and dry cotton swabs
 Watch with a second hand
 Blood pressure apparatus
 Stethoscope
 Personal Protective Equipment (PPE), as indicated
 Black/blue and red pens
 Vital signs chart
 Figure 1 - Requisites on a tray for vital signs assessment

Procedures

Assessing Axillary Temperature:

1. Perform hand hygiene and put on PPE, if indicated;
2. Identify the patient;
3. Introduce yourself;
4. Explain procedure to patient to gain consent;
5. Assess the patient’s ability to assist with the procedure;
6. Close curtains around bed and close the door to the room, if possible;
7. Ensure the electronic or digital thermometer is in working condition;

Figure 1 – Digital thermometer

Font: [Link]
instruction-manual#axzz80MG5mOjH

8. Wipe thermometer from bulb to stem;

9. Put on gloves, if appropriate or indicated;
10. Move the patient’s clothing to expose only the axilla;
11. Ensure axillae is dry;
12. Place the end of the probe in the center of the axilla. Have the patient bring the arm down and
close to the body;
13. When measurement is completed, remove gloves, if worn;
14. Remove additional PPE, if used;
15. Clean and store thermometer;
16. Perform hand hygiene;
17. Register the temperature.

Assessing Oral Temperature:

1. Perform hand hygiene and put on PPE, if indicated;
2. Identify the patient;
3. Introduce yourself;
4. Close curtains around bed and close the door to the room, if possible;
 5. Explain procedure to patient to gain consente;
6. Assess the patient’s ability to assist with the procedure;
7. Ensure the electronic or digital thermometer is in working condition;
8. Wipe thermometer from bulb to stem;
9. Put on gloves, if appropriate or indicated;
10. Place the probe beneath the patient’s tongue in the posterior sublingual pocket;
11. Ask the patient to close his or her lips around the probe;
12. Continue to hold the probe until you hear a beep;
13. Note the temperature Reading;
14. When measurement is completed, remove gloves, if worn;
15. Remove additional PPE, if used;
16. Clean and store thermometer;
17. Perform hand hygiene;
18. Register the temperature.

Assessing Rectal Temperature:

Additional requites: soft tissue, lubricant, disposable gloves.
1. Perform hand hygiene and put on PPE, if indicated;
2. Identify the patient;
3. Introduce yourself;
4. Close curtains around bed and close the door to the room, if possible;
5. Explain procedure to patient to gain consente;
6. Assess the patient’s ability to assist with the procedure;
7. Ensure the electronic or digital thermometer is in working condition;
8. Adjust the bed to a comfortable working height, usually elbow height of the care giver;
9. Wipe thermometer from bulb to stem;
10. Put on gloves;
11. Lubricate the bulb and approximately 1 inch above the bulb;
12. Position patient on their side, fold back clothing and separate the buttocks;
13. Insert the thermometer for approximately 1.5 inches in an adult, 1 inch in a child and 0.5 inch
in an infant;
14. Permit the buttocks to fall into place while holding the thermometer in place for 2-3 minutes;
15. Note the temperature Reading;
16. Remove the thermometer and wipe it once with soft tissue;
17. Wipe any residue of lubricant or stool remaining about the anus;
18. Cover the patient and help him or her to a position of comfort;
19. Place the bed in the lowest position; elevate rails as needed;
20. When measurement is completed, remove gloves, if worn;
21. Remove additional PPE, if used;
22. Clean and store thermometer;
23. Perform hand hygiene;
24. Register the temperature.

Assessing a Peripheral Pulse by Palpation:

1. Perform hand hygiene and put on PPE, if indicated;
2. Identify the patient;
3. Introduce yourself;
4. Close curtains around bed and close the door to the room, if possible;
5. Explain procedure to patient to gain consente;
6. Assess the patient’s ability to assist with the procedure;
7. Ask about activity level with in the last 15 minutes;
8. Select the appropriate peripheral site based on assessment data;
9. Move the patient’s clothing to expose only the site chosen;
10. Place your first, second, and third fingers over the artery;
 11. Lightly compress the artery so pulsations can be felt and counted;
12. Using a watch with a second hand, count the number of pulsations felt for 30 seconds. Multiply
this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse
is abnormal in any way, palpate and count the pulse for 1 minute;
13. Note the rhythm and amplitude of the pulse;
14. When measurement is completed, remove gloves, if worn;
15. Cover the patient and help him or her to a position of comfort;
16. Remove additional PPE, if used;
17. Perform hand hygiene;
18. Register the pulse.

Assessing Respiration:
1. Perform the assessment immediately after pulse is counted, with fingers still on pulse area so as
to reduce the patient’s consciousness when counting the respiration. While your fingers are still in
place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations;
2. Note the rise and fall of the patient’s chest;
3. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this
number by 2 to calculate the respiratory rate per minute. If respirations are abnormal in any way,
count the respirations for at least 1 full minute;
4. Note the respiratory rate (number of respiratory cycles), rhythm (regular or irregular), depth
(shallow, normal, or deep), type (thoracic, thoracoabdominal, or abdominal), and chest symmetry
(symmetric or asymmetric) during respiratory movementsrations;
5. When measurement is completed, remove gloves, if worn;
6. Cover the patient and help him or her to a position of comfort;
7. Remove additional PPE, if used;
8. Perform hand hygiene;
9. Register the respiration.

Monitoring Oxygen Saturation:

1. Review chart for any health problems that would affect the patient’s oxygenation status;
2. Bring necessary equipment to the bedside stand or overbed table;
3. Perform hand hygiene and put on PPE, if indicated;
4. Identify the patient;
5. Introduce yourself;
6. Close curtains around bed and close the door to the room, if possible;
7. Explain procedure to patient to gain consent;
8. Assess the patient’s ability to assist with the procedure;
9. Select an adequate site for application of the sensor:
 Use the patient’s index, middle, or ring finger;
 Check the proximal pulse and capillary refill at the pulse closest to the site;
 If circulation at the site is inadequate, consider using the earlobe, forehead, or bridge of nose;
 Use a toe only if lower extremity circulation is not compromised;
10. Select proper equipment:
 If one finger is too large for the probe, use a smaller one. A pediatric probe may be used for a
small adult;
 Use probes appropriate for patient’s age and size;
 Check if patient is allergic to adhesive. A nonadhesive finger clip or reflectance sensor is
available;
11. Prepare the monitoring site;
12. Cleanse the selected area with the alcohol wipe or disposable cleansing cloth;
13. Allow the area to dry. If necessary, remove nail polish and artificial nails after checking pulse
oximeter’s manufacturer instructions;
14. Apply probe securely to skin. Make sure that the light emitting sensor and the light-receiving
sensor are aligned opposite each other (not necessary to check if placed on forehead or bridge of
 nose);
15. Connect the sensor probe to the pulse oximeter, turn the oximeter on, and check operation of the
equipment (audible beep, fluctuation of bar of light or waveform on face of oximeter);

Figure 2 - Monitoring oxygen saturation

Font: Nurses’ guide to clinical procedures (2010)
16. Set alarms on pulse oximeter. Check manufacturer’s alarm limits for high and low pulse rate
settings;
17. Check oxygen saturation at regular intervals, as ordered by the doctor, nursing assessment, and
signaled by alarms;
18. Monitor hemoglobin level;
19. Remove sensor on a regular basis and check for skin irritation or signs of pressure (every 2 hours
for spring-tension sensor or every 4 hours for adhesive finger or toe sensor);
20. Clean no disposable sensors according to the manufacturer’s directions;
21. Remove PPE, if used;
22. Perform hand hygiene;
23. Register oxygen saturation.

Assessing Brachial Artery Blood Pressure:

1. Perform hand hygiene and put on PPE, if indicated;
2. Identify the patient;
3. Introduce yourself;
4. Close curtains around bed and close the door to the room, if possible;
5. Explain procedure to patient to gain consente;
6. Assess the patient’s ability to assist with the procedure;
7. Place patient in a relaxed position, support the arm;
8. Ensure that the patient:
 Has an empty bladder;
 Has not engaged in physical exercise for at least 60 minutes;
 Has not consumed alcoholic beverages or coffee;
 Has not smoked in the past 30 minutes;
9. Ensure the cuff is the appropriate size. Verify the patient's brachial circumference (BC) to
determine the size of the cuff to be used: draw a line between the acromion and olecranon,
identify the midpoint, and measure the BC (the cuff width should correspond to 40% of the BC and
cover at least 80% to 100% of the arm). Example: BC = 28 cm, appropriate cuff is the adult one
with 13 cm in width and 30 cm in length. 40% of 28 cm = 11.2 cm and 80% of 28 cm = 22.4 cm;
10. Palpate for the brachial artery at the region of the ante-cubital fossa/space. The arm should be at
heart level (level of the midpoint of the sternum or fourth intercostal space), free of clothing,
supported, with the palm facing up and the elbow slightly flexed;
11. Wrap cuff snugly and smoothly around the upper part of the arm, 2 inch above the ante-cubital
space. Do not allow any clothing to interfere with the proper placement of the cuff;
12. Keep pressure level at zero;
 Figure 3 – Parts of the sphygmomanometer
Font: [Link]

13. Locate radial artery pulsations on cuffed arm;

14. Estimate Systolic Pressure:
 Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips;
 Tighten the screw valve on the air pump;
 Inflate the cuff while continuing to palpate the artery;
 Note the point on the gauge where the pulse disappears;
 Deflate the cuff and wait 1 minute;
15. Obtain Blood Pressure Measurement:
 Assume a position that is no more than 3 feet away from the gauge;
 Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal and
not against the ear itself;

Figure 4 – Parts of the stethoscope

Font: [Link]

 Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible
over the brachial artery;
 Do not allow the stethoscope to touch clothing or the cuff;
 Pump the pressure 30 mm Hg above the point at which the systolic pressure was palpated and
 estimated. Open the valve on the manometer and allow air to escape slowly (allowing the
gauge to drop 2 to 3 mm per second);
 Note the point on the gauge at which the first faint, but clear, sound appears that slowly
increases in intensity;
 Note this number as the systolic pressure. Read the pressure to the closest 2 mm Hg;
 Do not reinflate the cuff once the air is being released to recheck the systolic pressure Reading;
 Note the point at which the sound completely disappears;
 Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait at least 1
minute;
 Deflate the cuff completely between attempts to check the blood pressure;
16. When measurement is completed, remove the cuff;
17. Remove gloves, if worn;
18. Cover the patient and help him or her to a position of comfort;
19. Remove additional PPE, if used;
20. Perform hand hygiene;
21. Clean the diaphragm of the stethoscope with the alcohol wipe;
22. Clean and store the sphygmomanometer, according to facility policy;
23. Register the bloody pressure.

Nb: Chart all abnormal findings with RED ink pen and report according to need or doctor's order.
Nursing documentation
Date and Time: Verified right axillary T = 98.96°F (37.2°C), normothermic, patient seated. Right
radial pulse checked = 82 bpm, normocardic, rhythmic, strong, patient seated. Finger sensor
(probe) applied to left index finger; capillary refill brisk, radial pulse present. Respiratory rate
checked on [date] at [time]: RR= 18 bpm, eupneic, regular, deep, abdominal, and symmetric,
patient sitting. Pulse oximeter yielding SaO2 of 96% on room air. BP checked = 126 x 82 mmHg on
the right upper limb, normotensive, patient seated, arm circumference = 28cm, and adult cuff
13cm wide and 30cm long was used. Name of the professional, position, and Guyana Nursing
Registration.
References
1. Lynn, P.B. (2022) Taylor's Clinical Nursing Skills (6th Ed.). Wolters Kluer.
2. Potter, P.A.; Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
3. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
4. Smith-Temple J, Johnson JY. Nurses’ guide to clinical procedures. 6th ed. Philadelphia:
Walters Kluwer & Lippincott Williams & Wilkins; 2010. 966 p.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment I:
TEPID SPONGING
Related Course(s) Clinical skills
Theoretical content Tepid sponging
Definition Tepid sponging is the application of tepid water (water matching body or room
temperature) (23.9– 26.8 oC or 75–80 oF) on the skin of a febrile person/ client
with a sponge or piece of cloth to reduce or restore body temperature.
Rationale  To reduce elevated set point (body temperature) to within normal range
by evaporation.
 To promote comfort in the febrile person/client.
 To prevent complications of fever (convulsion, deliriums) and excessive
sweating.
 To promote recovery in the person’s/client’s condition.
Principles  The range in body temperature in which the cells can function efficiently is
approximately 96–100 oF (36–38 °C).
 Body temperature is controlled by regulation of the rate at which the
tissues produce heat and the rate of which heat is lost from the body.
 Peripheral vasodilation if prolonged can produce chilling.
 Cold applications conduct heat from the body tissues.
 Heat is lost from the body by radiation, evaporation, conduction and
convection.
 The amount of heat produced by the body can be decreased to prevent
over heating by:
 Application of tepid water on the skin for evaporation.
 Decreasing the cellular metabolic activity.
 Decreasing muscle activity.
 Increasing fluid intake.
 As heat production is increased, it is accompanied by vasodilation, flushing
and uncomfortable sensation of warmth, until the body fluids and tissues
reach the elevated temperature of the hypothalamus thermostat.
 Heat is lost from the skin by radiation, vaporization, convection and
conduction. The proportion of heat lost in these different ways varies with
the condition of the body and with the temperature and humidity of the
environment.
Requisities  Large bowl with tepid water
 Container with 6-8 small rags or gauze squares
 Cold pack (for fore head)
Cool liquid (optional)
Bath towel
 Bath blanket (to cover when patient complains of feeling cold)
 Bath thermometer
 Patient thermometer

Figure 1 - Requisites on a tray for tepid sponging

Procedures
1. Observe patient for elevated temperature. Review physician’s orders.
 2. Perform hand hygiene.
3. Put on PPE, as indicated.
4. Identify the patient.
5. Introduce yourself.
6. Explain procedure to patient to gain consent.
7. Assess the patient’s ability to assist with the procedure.
8. Close curtains around bed and close the door to the room, if possible.
9. Use large mackintosh to protect mattress if there is no protective cover.
10. Cover patient with blanket (to prevent chilling), remove clothing under cover and close windows
and doors.
11. Test the water temperature (A tepid sponge bath generally refers to one in which the water
temperature is between 90 °F and 98 °F throughout the bath).
12. Place washcloths in water and then apply wet cloth on the forehead for comfort and in each axilla
and the groin area. These areas contain large superficial blood vessels that help the transfer of
heat, and change as they become warm.
13. Exposing one body area at a time, sponge the face, arms, legs, back, and buttocks for 3 to 5
minutes each. The chest and abdomen are not usually sponged. Each area is sponged slowly and
gently. Rubbing may increase heat production.
14. Pat each area dry with a towel.
15. Reassess the patient’s temperature 15 minutes after completing the sponge bath.
16. Continue with sponge bath until body temperature falls slightly above normal.
17. Dry patient thoroughly, and cover with light blanket or sheet.
18. Remove gloves, if worn.
19. Remove additional PPE, if used.
20. Perform hand hygiene.
21. Monitor temperature every 30 minutes, when normal, monitor every 2 hours.
22. Return equipment to storage, clean area, and change bed linens as necessary.
23. After this procedure, a cold glass of water is usually offered to aid in the process.
24. Document patient’s temperature taken prior to starting the tepid bath, and after the bath. Also
document the patient’s response to the bath and the duration time of the bath.
Nb:
Do not apply cold water or ice to the patient’s skin. This causes stimulation of the thermo
receptors that initiates shivering before the brain temperature cools.
 Patient can also be given cool liquids to drink.
 Heat can also be lost through methods of convection, conduction, radiation and evaporation.
 Patient’s temperature should be reduced by LYSIS not CRISIS.
Nursing documentation
Date and Time: Tepid sponge bath administered to trunk and extremities for 20 min because
client’s temperature is 104.78F. Temperature after bath, 102.68F; pulse, 118 bpm and regular;
respirations, 28 breaths/min and regular; BP, 110/62 mm Hg. Client tolerated procedure well.
Dozing quietly in bed in supine position. Doctor notified of status. Name of the professional,
position, and Guyana Nursing Registration.
References
1. Lynn, P.B. (2022) Taylor's Clinical Nursing Skills (6th Ed.). Wolters Kluer.
2. Potter, P.A.; Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
3. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
 Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment J1:
BED BATH
Related Course(s) Health assessment
Nursing process
Theoretical content Hygiene care
Definition Bathing the patient in bed in which the entire body of the patient is washed and
dried in bed by the nurse.
Rationale  To cleanse the skin to remove accumulated perspiration, secretion,
microorganisms and debris.
 To provide comfort and relaxation to a tired and restless person.
 To stimulate circulation both systemically and locally.
 To promote muscle tone by active and passive movements.
 To promote elimination from the skin.
 To prevent lung congestion by stimulating respiration through change in
position.
 To improve self-image, self-esteem.
 To observe skin condition and objective symptoms.
Principles  People are less fearful and more cooperative when they know what to
expect.
 The amount of knowledge a patient requires depends upon the individual
circumstances e.g., age, level of intelligence, consciousness, health status
etc.
 Warm water tends to relax muscles and increase circulation by dilatation
of blood vessels.
 Soap decreases surface tension of water and this aids in more efficient
cleansing. It is however an irritant to certain delicate tissues.
 The dangling end of the wash rag is a means of annoyance to the patient.
 Non-judgemental, tactful and competent behaviors are reassuring to
people.
 Healthy skin is relatively dry, therefore a macerated skin resulting from
continuous excessive moisture and dryness, which result in cracking,
decreases the skin’s resistance to pressure and infection.
 Follow the principles head to toes and clean to dirty.
 Complete bed bath is recommended for patients who are totally
dependent and require total hygiene care. It is an activity that can be
exhausting for them. Turning during a complete bed bath and receiving
back care has been shown to increase oxygen consumption in healthy men
and women. Measuring heart rate before, during and after the bath
provides a measure of patient physical tolerance.
Requisities Top shelf:
 Equipment for mouth nail and hair care
 Container with soap
 Bath thermometer
 2 wash rags
 Patient’s toiletries: soap or emollient, and deodorant
 Disposable gloves

Bottom shelf:
 2 large bowls
 Jugs with hot and cold water
 1 large mackintosh
 Face towel
 Bath towels 2/bath blanket
  Covered bed pan/urinal
 Linen for bed making
 Patient’s clothing
 Tissue paper
 Covered pails (water and bed linen)

Figure 1 - Requisites on a tray for bed bath

Procedures:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure to patient to gain consent.
5. Close curtains around bed and close the door to the room, if possible.
6. Assess the patient’s ability to assist with the procedure.
7. Encourage the patient to assist with care to promote independence.
8. Raise the bed to allow you to comfortably work.
9. Lower the side rail on the side where you are working, raise it when moving to the other side of
the bed.
10. Put on the gloves.
11. Prepare water for bathing (temperature approximately 100-115 °F). Fill basin about two-thirds.
12. Assist the patient to move toward the side of the bed where you will be working.
13. Protect bed with mackintosh.
14. Cover the patient’s body with a towel or blanket.
15. Remove the patient’s clothing under the cover (to keep patient warm, uncover only parts being
bathed and dry each area before washing the next).
16. Put towel under the patient’s body from the head to waist.
17. Place face towel under the chin.
18. Make a mitt with wash rag, clean face, neck and ears first dry carefully. When cleaning the
patient’s eyes, cleanse from inner to outer corner with plain water.
19. Wash arms and hands. Use long strokes: wrist to elbow→ elbow to shoulder→ axilla→ hand.
20. Wash chest and abdomen.
21. Clean under the breasts if it is the case.
22. Move the towel that’s under the patient’s body to the level of the waist to behind the knee.
23. Wash legs and feet. Wash from foot joint to knee→ from knee to hip joint.
24. Repeat the same on the other side.
25. Change water.
26. Turn the patient on left lateral position with back towards you.
27. Wash and dry the back, behind the legs and buttocks.
28. Return the patient to the supine position.
29. Change the water and don procedures gloves before cleansing the perineum. Change the water
whenever it becomes dirty or cold
30. Wash the perineal area:
a) Place bed pan under patient.
b) Separate the labia and cleanse downward from the pubic to anal area for women and
cleanse in a circular motion moving from the tip of the penis backwards toward the pubic
area, in an uncircumcised male, carefully retract the foreskin prior to washing the penis.
31. Rinse well and pat dry. Pat the skin dry, do not rub.
 32. Assist the patient to wear clean clothing and cosmetics (deodorant, skin lotion).
33. After bed bath, make the bed tidy and leave patient in a comfortable position.
34. Return the proper place for personal belongings after drying up.
35. Replace all instruments.
36. Remove gloves.
37. Remove additional PPE, if used.
38. Perform hand hygiene.
39. Document the care provided.
Nursing documentation
Date and Time: Bed bath performed and moisturizer applied, communicative and cooperative
patient. Intact skin and mucous membranes. Patient repositioned to right lateral decubitus at the
end of the bath. Name of the professional, position, and Guyana Nursing Registration.
References
1. Lynn, P.B. (2022) Taylor's Clinical Nursing Skills (6th Ed.). Wolters Kluer.
2. Potter, P.A.; Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
3. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment J2:
HAIR CARE
Related Course(s) Health assessment
Nursing process
Theoretical content Hygiene care
Definition This is the regular grooming of the hair and scalp for a patient who is unable do it
for his/her self. It may include combing, brushing and shampooing of the hair.
Rationale  To Promote growth of clean and healthy hair.
 To maintain personal hygiene of the client.
 To increase circulation to the scalp and hair and promote growing of hair.
 To make him/her feel refreshed.
Principles  The integrity of the skin and mucous membrane is a defense which
protects the body from the invasion of microorganisms.
 Transient bacteria are removed by thorough washing with soap and water.
 Microorganisms live everywhere in the environment but can become
pathogenic when they are removed from their normal place of habitat.
 Healthy skin is relatively dry, therefore a macerated skin resulting from
excessive moisture and dryness, results in cracking, decreases the skin’s
resistance to pressure and infection.
 Soap reduces surface tension of water and contacting surfaces. It is
however an irritant certain delicate tissue and makes the skin dry if left on.
 Comfort and well-being of the individual are dependent on both physical
and psychosocial factors.
 Warm water tends to relax muscles and increase circulation by dilatation
of blood vessels.
Requisities  2 mackintoshes
 2 big towels
 Medium towel
 Cotton balls
 Shampoo or soap
 Hair oil, if necessary
 Brush, comb:
 Jugs with water (1 hot and 1 cold)
 Cushion or pillow
 Container for collecting waste water
 Cloth pin or clips
 Clean cloth if necessary

Figure 1 - Requisites on a tray for hair care

Procedures:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
 3. Introduce yourself.
4. Explain procedure to patient to gain consent.
5. Assess the patient’s ability to assist with the procedure.
6. Assemble equipment on overbed table within reach.
7. Close curtains around bed and close the door to the room, if possible.
8. Lower the head of the bed. Remove pillow and place protective pad under patient’s head and
shoulders.
9. Fill the pitcher with warm water (43-46 °C or 110-115 °F).
10. Help the client move his/her head towards edge of the bed and remove the pillow from the head.
11. Place a mackintosh, and a big towel under the client head to the shoulders.
12. Roll another mackintosh to make the shape of a funnel, the narrow end should be folded and put
under the client’s neck and the free end should be put into the bucket to drain for the
wastewater.
13. Put the folding mackintosh under the client’s neck to prevent the sheet from soiling.
14. Brush the hair.
15. Insert the cotton balls into the ears.
16. Pour pitcher of warm water slowly over patient’s head, making sure that all hair is saturated. Refill
pitcher, if needed.
17. Apply a small amount of shampoo to patient’s hair.
18. Massage deep into the scalp, avoiding any cuts, lesions, or sore spots.
19. Rinse with warm water (43-46 °C or 110-115 °F) until all shampoo is out of hair. Repeat shampoo,
if necessary.
20. If patient has thick hair or requests it, apply a small amount of conditioner to hair and massage
throughout.
21. Avoid any cuts, lesions, or sore spots.
22. If drain container is small, empty before rinsing hair.
23. Rinse with warm water (43-46 °C or 110-115 °F) until all conditioner is out of hair.
24. Remove shampoo board. Place towel around patient’s hair.
25. Pat hair dry, avoiding any cuts, lesions, or sore spots.
26. Remove protective padding but keep one dry protective pad under patient’s hair.
27. Gently brush hair, removing tangles as needed.
28. Blow-dry hair on a cool setting, if allowed and if patient wishes. If not, consider covering the
patient’s head with a dry towel, until hair is dry.
29. Change patient’s gown and remove protective pad.
30. Replace pillow.
31. Remove equipment and return patient to a position of comfort.
32. Remove your gloves, if worn.
33. Raise side rail and lower bed.
34. Remove additional PPE, if used.
35. Perform hand hygiene.
36. Document the care provided and report any abnormalities.
Nursing documentation
Not applicable
References
1. Lynn, P.B. (2022) Taylor's Clinical Nursing Skills (6th Ed.). Wolters Kluer.
2. Potter, P.A.; Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
3. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment J3:
ORAL CARE
Related Course(s) Health assessment
Nursing process
Theoretical content Hygiene care
Definition Oral hygiene is the practice of keeping the mouth clean and healthy by brushing
and flossing to prevent tooth decay and gum disease. This is the method of
cleaning and freshening teeth, gums and tongue.
Rationale  To freshen the mouth and relieve it of plaque and offensive odors.
 To keep the lips and mucosa clean, soft, moist intact.
 To prevent oral infections and other complications.
 To remove food debris.
 To enhance appetite.
 To improve self-concept and body image.
 To provide a sense of wellbeing and comfort to the patient.
Principles  The integrity of the skin and mucous membrane is a defense which
protects the body from the invasion of microorganisms.
 Pathogenic organisms may be destroyed by sufficient heat or chemical
agents.
 Healthy teeth promote proper digestion of food for the patient’s
nutritional status.
 Frequent and persistent cleaning of the entire mouth is necessary to avoid
accumulation of microorganisms and food particles.
 Healthy teeth and gums promote the patient’s comfort sense of well-being
and self-esteem.
 Dental caries increase risk for abscesses/oral infections.
 Teeth, gums, and tongue should be brushed at least twice a day using a
soft, compact head (pediatric or adult) toothbrush.
 Oral moisturizing to oral mucosa and lips should be provided every 2 to 4
hours.
 Oral chlorhexidine gluconate (0.12%) rinse should be used twice a day in
intubated patients to reduce risk of VAP.
 There is no recommendation for routine use of oral chlorhexidine
gluconate (0.12%) in nonintubated patients at this time.
Requisities  Towel
 Disposable gloves
 Gauze-padded tongue depressor
 Toothpaste/mouth wash
 Tooth brush/sponge tipped applicator
 Oral chlorhexidine gluconate (0.12%) rinse, if applicable
 Torch light
 Container with water
 Container for dentures if applicable
 Small rag
 Sputum container
 Disposable cup with water
 Denture pot and denture cleaning agent and brush
 Lips moisturizer (Vaseline / glycerin / paraffin gel / lip balm)
Procedures
Independent Patients:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
 4. Explain procedure and gain consent.
5. Assess the patient’s ability to assist with the procedure.
6. Explain to the patient that his/her mouth is to be examined and cleaned.
7. Provide privacy for patient.
8. Assemble equipment on overbed table within patient’s reach.
9. Place patient in appropriate position.
10. Protect patient’s clothing with water repellant cape or towel.
11. Raise the bed to allow you to comfortably work.
12. Put on the gloves.
13. Soften bristles of toothbrush by immersing in cool fresh water, then apply toothpaste on bristles.
14. Instruct the patient to brush teeth along direction of growth, to remove food debris from grooves.
One section of mouth should be done at a time.
15. Ask the patient to rinse with fresh water and void contents into the sputum container.
16. Advise him/her not to swallow water.
17. Ask the patient to wipe mouth and around it.
18. Confirm the condition of patient’s teeth, gums and tongue.
19. Offer lubricant to lips.
20. Dentures are cleaned under running water and brushed in the same way as the teeth.
21. Rinse and dry tooth brush thoroughly.
22. Return the proper place for personal belongings after drying up.
23. Replace all instruments.
24. Remove gloves, if used.
25. Remove additional PPE, if used.
26. Perform hand hygiene.
27. Document the care provided and report any changes noted.

Dependent Patient:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure and gain consent.
5. Assess the patient’s ability to assist with the procedure.
6. Explain to the patient that his/her mouth is to be examined and cleaned.
7. Provide privacy for patient.
8. Assemble equipment on overbed table.
9. Lower side rail and assist patient to sitting position, if permitted, or turn patient onto side.
10. Drape a towel over the patient’s chest.
11. Raise the bed to allow you to comfortably work.
12. Put on the gloves.
13. Raise the head of the patient to an angle no greater than 30 degrees.
14. Gently turn the patient’s head toward you, and open the mouth using a tongue depressor in one
hand.
15. Inspect the mouth, using the wooden spatula to hold the tongue down gently. Care should be
taken not to place the spatula too far back on the tongue as this may induce the gag reflex and
make the patient frightened and uncomfortable.
16. Remove any partial or full plates or dentures.
17. Using a toothbrush or sponge tipped applicator, place it at a 45-degree angle to gum line and
brush from gum line to crown of each tooth. Brush outer and inner surfaces. Brush back and forth
across biting surface of each tooth.
18. Brush tongue gently with toothbrush.
19. Use only a small amount of toothpaste to prevent excess from being swallowed.
20. Have patient rinse vigorously with water and spit into emesis basin. Repeat until clear. Suction
may be used as an alternative for removal of fluid and secretions from mouth.
21. Offer mouthwash if patient prefers.
 22. Offer lubricant to lips.
23. Assist your patient back into a comfortable position.
24. Dentures are cleaned under running water and brushed in the same way as the teeth.
25. Rinse and dry tooth brush thoroughly.
26. Return the proper place for personal belongings after drying up.
27. Replace all instruments.
28. Remove gloves.
29. Remove additional PPE, if used.
30. Perform hand hygiene.
31. Document the care provided and report any changes noted.

Unconscious Patient:
This oral care procedures applies to all patients who are intubated or have a tracheostomy. Verify that
order has been obtained for chlorhexidine 0.12% mouth wash. Rule out contraindications including severe
mucositis or allergy to chlorhexidine.

Requisites
 Goggles or glasses and mask
 Bite-block or oral airway if needed
 Adhesive or twill tape
 Gauze or cotton swab for cleaning around the nares
 Normal saline solution
 Soft pediatric/adult toothbrush or suction toothbrush
 Foam oral swab or oral suction swab
 Oral cleansing solution (oral chlorhexidine 0.12%, toothpaste)
 Suction catheter for oral and nasal suctioning
 2 sources of suction or a bifurcated connection device attached to a single suction source
 Nonsterile gloves
 Stethoscope

Procedures:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure.
5. Provide privacy for patient.
6. Assemble equipment on overbed table.
7. Lower side rail and assist patient to sitting position, if permitted, or turn patient onto side.
8. Assess for signs and symptoms that indicate that oral cavity care is necessary (i.e., excessive
secretion, dry oral mucosa, debris in the oral cavity, plaque buildup on teeth, etc).
9. Drape a towel over the patient’s chest.
10. Raise the bed to allow you to comfortably work.
11. Put on the gloves and facemask.
12. Maintain the patient at semi-Fowler’s (≥ 30 degrees).
13. Inspect oral cavity using a flashlight and a 4 X 4 gauze to facilitate lifting/moving of the tongue.
14. Inspect top, sides and undersurface of tongue. Assess lips, back of throat and mucous membranes
for any bleeding, odor, discharge or evidence of skin breakdown or ulceration.
15. Inspect teeth to observe for breakage, missing teeth, dental carries or recent trauma. Consider
need for dentistry consult.
16. Initiate oral hygiene with pediatric or adult soft toothbrush, at least twice a day.
17. Gently brush patient’s teeth to clean and remove plaque.
18. Suction oropharyngeal after brushing.
19. Use toothpaste or cleansing solution that assists in the breakdown of debris.
20. In addition to brushing twice daily, use oral chlorhexidine 0.12% rinse twice a day.
 21. Wait at least 2 hours following chlorhexidine or oral nystatin (if used) before brushing teeth with
toothpaste or using mouth washes.
22. Suction oropharyngeal after cleansing.
23. Apply a lip moisturizer.
24. After oral hygiene is completed, change the endotracheal tube securing mechanism with a new
tape, ties, or commercial device, as needed, according to institutional standard.
25. Ensure proper cuff inflation.
26. Reconfirm tube placement, and note position of tube at teeth, gumline or nares.
27. Remove and discard supplies.
28. Replace all instruments.
29. Remove gloves.
30. Remove additional PPE, if used.
31. Perform hand hygiene.
32. Document the care provided and report any changes noted.
Nursing documentation
Not applicable
References
1. American Association of Critical-Care Nurses (2017) Oral care for acutely and critically ill
patients. Crit Care Nurse; 37(3):e19–e21. doi: [Link]
2. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L. (2022) Fundamentals of nursing: the art and science of
person-centered care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment J4:
PERINEAL CARE
Related Course(s) Health assessment
Nursing process
Theoretical content Hygiene care
Definition Perineal care is cleaning the perineum, the external genitalia and surrounding skin.
Rationale  To prevent or eliminate infection or odor.
 Promote healing.
 Restore perineal integrity.
 Remove secretions.
 Promote comfort and cleanliness.
 Prevent perineal dermatitis.
 Prevent recurrent damage.
Principles  The integrity of the skin and mucous membrane is a defense which
protects the body from the invasion of microorganisms.
 Transient bacteria are removed by thorough washing with soap and water.
 Microorganisms live everywhere in the environment but can become
pathogenic when they are removed from their normal place of habitat.
 Healthy skin is relatively dry, therefore a macerated skin resulting from
excessive moisture and dryness, results in cracking, decreases the skin’s
resistance to pressure and infection.
 Soap reduces surface tension of water and contacting surfaces. It is
however an irritant certain delicate tissue and makes the skin dry if left on.
 Most bacteria prefer a neutral or slightly alkaline environment, therefore
the skin secretion which has a pH of 5.5 are bacteriostatic.
 When the integrity of the skin is broken, routes of entry are opened for
pathogenic microorganisms.
Requisities Prepare requisites on a tray (Figure 1):
 Disposable gloves
 Sponge cloth
 Basin with warm water
 Waterproof pad or mackintosh
 Towels
 Soap
 Toilet paper
 Bed pan

Figure 1 - Requisites on a tray for perineal care

Procedures
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure to patient to gain consent.
5. Assess the patient’s ability to assist with the procedure.
 6. Close curtains around bed and close the door to the room, if possible.
7. Assemble equipment on overbed table.
8. Fill basin with water at correct temperature to patient’s preference, if applicable.
9. Cover the patient appropriately to avoid exposure and maintain dignity.
10. Place patient in appropriate position.
11. Place a waterproof pad / mackintosh under buttocks.
12. Ask the patient to open his or her legs if he/she is able. If not, you will need to gently separate the
legs.
13. Wet washcloths and apply cleansing solution.
14. Make a mitt with the sponge cloth cleanse the patient's upper thighs and groin area with soap and
water.
15. Rinse and dry.
16. Wash perineal area:

 Females:
 Separate the labia.
 Clean front to back using downward strokes.
 Use a clean area of the cloth for each downward motion.
 Repeat using additional cloths, as needed.
 Do not move from back to front due to the risk of introducing germs from the anal area
into the urethra, a primary source of urinary tract infection.

 Males:
 Retract foreskin in uncircumcised male.
 Grasped penis, clean tip of penis using a circular motion, wash down shaft of the penis
and testicles.
 Replace foreskin of uncircumcised male.

17. Rinse the perineal area.

18. Turn the patient on their side facing away. Clean anal area using toilet paper, if necessary, to
remove fecal materials then wash from front to back.
19. Pat area dry thoroughly, to prevent skin from becoming chapped.
20. Apply skin care products to the area according to need or doctor's order.
21. Remove waterproof pad and discarded.
22. Never reuse linens used to clean the perineal area to clean any other part of the body. Use a
clean washcloth for this area only to minimize the spread of germs.
23. Return the patient to a comfortable position.
24. Replace all instruments.
25. Remove gloves.
26. Remove additional PPE, if used.
27. Perform hand hygiene.
28. Document the care provided and report any changes noted.
Nursing documentation
Not applicable
References
1. Lynn, P.B. (2022) Taylor's Clinical Nursing Skills (6th Ed.). Wolters Kluer.
2. Potter, P.A.; Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
3. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
 Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment J5:
NAIL CARE
Related Course(s) Health assessment
Nursing process
Theoretical content Hygiene care
Definition This is the care given to toenails and fingernails to promote a clean, neat,
attractive appearance and prevent skin infection and other infections related poor
nail hygiene.
Rationale  To keep the hands and feet clean.
 To promote the growth of healthy nails.
 To protect the nails from injury and trauma.
 To avoid infection and other complications caused by dirty nails.
 To maintain skin integrity (skin health).
 To keep the skin moisturized.
 To keep nails short, but not too short.
 To provide a sense of neatness, cleanliness and well-being.
 To improve self-esteem.
Principles  The integrity of the skin and mucous membrane is a defense which
protects the body from the invasion of microorganisms.
 Transient bacteria are removed by thorough washing with soap and water.
 Microorganisms live everywhere in the environment but can become
pathogenic when they are removed from their normal place of habitat.
 Healthy skin is relatively dry, therefore a macerated skin resulting from
excessive moisture and dryness, results in cracking and decreases the
skin’s resistance to pressure and infection.
 Soap reduces surface tension of water and contacting surfaces. It is
however an irritant certain delicate tissue and makes the skin dry if left on.
Requisities A tray may be used. Prepare the following requisites (Figure 1):
 1 mackintosh
 1 towel
 A wash rag
 A kidney dish with warm water
 Orange stick, cotton tip swabs, nail brush
 Soap
 Hand cream
 Pair of disposable gloves
 Container for used instruments

Figure 1 – Requisites for nail care

Procedures
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure to patient to gain consent.
5. Assess the patient’s ability to assist with the procedure.
 6. Assist patient in a comfortable position.
7. Spread the mackintosh over bed table / bed.
8. Place the kidney dish with warm mild soap water on the bed table.
9. Soak fingers in the warm water for 10 to 20 minutes.
10. Replace the patient hand over the mackintosh.
11. Perform hand hygiene and put on gloves.
12. Brush nails, scrub and wash patient’s hands thoroughly.
13. Use cotton tipped swabs or orange stick to clean gently under the nails.
14. Dry hands with towels, wipe all fingernails.
15. Trim patient' nails with nail clip if necessary.
16. Shape finger nails with nail file, rounding the corners then dry both hands thoroughly.
17. Apply lotion to hands.
18. Repeat the procedure for the second hand and feet.
19. Assist patient back into a comfortable position.
20. Discard all waste according to Hospital Policy.
21. Wash dry and replace equipment.
22. Remove gloves.
23. Remove additional PPE, if used.
24. Perform hand hygiene.
25. Inspect nails and surroundings to detect any complication.
26. Document the care provided and report any skin or nail issues or changes noted with the patient.
Nursing documentation
Not applicable
References
1. Centers for Disease Control and Prevention. Nail hygiene. CDC, 2022. Available at: <
[Link] Access at: May 17, [Link], P.A.;
Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
2. Chippewa Valley Technical College. (2022, December 3). Nail Care. [Video]. YouTube. Video
licensed under CC BY 4.0. [Link]
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment K:
PRESSURE AREA CARE
Related Course(s) Health assessment
Theoretical content Pressure Area Care
Definition Treatment that is applied to the skin covering, bony prominences, which are
subjected to constant pressure as a result of being confined to bed. Care of
pressure area must be carried out two hourly along with change of the patient
position.
Rationale  To stimulate circulation in the skin subjected to pressure.
 To keep the skin supple and fresh.
 To protect the skin from moisture associated with incontinent patient.
 To protect the skin surface breaking down to form pressure injuries.
 To promote and maintain physical and medical comfort.
 To observe the general state of the patient’s skin.
Principles  In the past, massage was traditionally used for pressure injury prevention.
Currently, this practice is contraindicated because it can cause tissue
damage due to rupture of already dilated capillaries and reperfusion
injury.
 Nurses need to manage the incontinence to reduce skin exposure to
excess moisture and chemical irritants from urine and stool.
 It is imperative to minimize skin injury from friction and shearing forces by
using proper positioning, turning, and transferring techniques.
 Nurses should use lubricants, protective films, dressings, and padding to
diminish the effects of friction on the skin.
 Nurses should conduct a comprehensive skin and tissue assessment for all
individuals at risk of pressure injuries.
 Nurses should regularly monitor the tension of medical device
securements and where possible seek the individual’s self-assessment of
comfort.
 Nurses need to consider:
 Individuals with limited mobility, limited activity and a high potential
for friction and shear to be at risk of pressure injuries.
 The potential impact of pain at pressure points on pressure injury risk.
 The impact of diabetes mellitus on the risk of pressure injuries.
 The impact of perfusion and circulation deficits on the risk of pressure
injuries.
 The impact of oxygenation deficits on the risk of pressure injuries.
 The impact of impaired nutritional status on the risk of pressure
injuries.
 The potential impact of moist skin on the risk of pressure injuries.
 The impact of increased body temperature on the risk of pressure
injuries.
 The potential impact of older age on the risk of pressure injuries.
 The potential impact of impaired sensory perception on the risk of
pressure injuries.
 The potential impact of laboratory blood test results on the risk of
pressure injuries.
 The potential impact of general and mental health status on pressure
injury risk.
 The impact of time spent immobilized before surgery, the duration of
surgery and the American Society of Anesthesiologists (ASA) Physical
Status Classification on surgery-related pressure injury risk.
 The following as additional risk:
  Factors for the development pressure injuries in critically ill
individuals: duration of critical care stay; mechanical ventilation;
use of vasopressors; Acute Physiology and Chronic Health
Evaluation (APACHE II) score.
 The impact of skin maturity, perfusion and oxygenation, and presence of a
medical device on pressure injury risk in neonates and children.
Requisities Prepare requisites on a tray:
 Flashlight, if needed (for skin inspection)
 Thermometer for body temperature
 Container for warm water, mild soap, and bath gloves, if necessary (for
cleansing)
 Bath towel, if necessary
 Disposable diaper, if necessary
 A high absorbency incontinence product, if necessary
 Skin moisturizers / barrier products
 Pressure redistribution cushions
 Heel suspension device or a pillow/ foam cushion
 Prophylactic dressing
 Support surfaces, as indicated
Procedures:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure to patient to gain consent.
5. Close curtains around bed and close the door to the room, if possible.
6. Assess the patient’s ability to assist with the procedure.
7. Turn back patient’s clothes to expose the skin area.
8. Put on the gloves if necessary.
9. Inspect the skin of individuals at risk of pressure injuries to identify presence of erythema.

Figure 1 – Patient positions

Font: Richardson, R. and J. Keeling, Clinical skills: an introduction for nursing and healthcare.
2021, United Kingdon: Latern Publishing Ltd. 280p.

10. Differentiate blanchable from non-blanchable erythema using either finger pressure or the
transparent disk method and evaluate the extent of erythema.
11. Assess the body temperature with a thermometer and the temperature of skin and soft tissue
through palpation.
12. Assess edema and assess for change in tissue consistency in relation to surrounding tissues.
 13. Implement a skin care regimen that includes:
a) Keeping the skin clean and appropriately hydrated.
b) Cleansing the skin promptly after episodes of incontinence.
c) Avoiding use of alkaline soaps and cleansers.
d) Avoid vigorously rubbing skin that is at risk of pressure injuries.
e) Use high absorbency incontinence products to protect the skin in individuals with or at risk of
pressure injuries who have urinary incontinence.
f) Protecting the skin from moisture with a barrier product.
14. Consider using textiles with low friction coefficients for individuals with or at risk of pressure
injuries.
15. Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of
pressure injuries.
16. Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless
contraindicated.
17. Determine repositioning frequency with consideration to the individual’s level of activity, mobility
and ability to independently reposition.
18. Use the 30° lateral side lying position in preference to the 90° side lying position when positioning.
19. Keep the head of bed as flat as possible, unless contraindicated.
20. Promote seating out of bed in an appropriate chair or wheelchair for limited periods of time.
21. Assess the vascular/perfusion status of the lower limbs, heels and feet when performing a skin
and tissue assessment, and as part of a risk assessment.
22. Elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion
for individuals at risk of heel pressure injuries and/or with Category/Stage I or II pressure injuries.
Offload the heel completely in such a way as to distribute the weight of the leg along the calf
without placing pressure on the Achilles tendon and the popliteal vein.
23. Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel
pressure injuries.
24. Select a support surface that meets the individual’s need for pressure redistribution based on the
following factors:
a) Level of immobility and inactivity.
b) Need to influence microclimate control and shear reduction.
c) Size and weight of the individual.
d) Number, severity and location of existing pressure injuries.
e) Risk for developing new pressure injuries.
25. Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who
are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to
perform pressure relieving maneuvers.
26. Assess the skin under and around medical devices for signs of pressure related injury as part of
routine skin assessment.
27. Replace all instruments.
28. Remove gloves, if used.
29. Remove additional PPE, if used.
30. Perform hand hygiene.
31. Document care provided, measures used to prevent pressure injuries, and the results of these
interventions.
Nursing documentation
Date and Time: Performed patient assessment according to individualized care plan and
identified the presence of moderate risk for pressure injury development, with a score of 16 on
the Braden scale. Repositioned the patient every 2 hours, using positioning cushions to protect
high-risk areas. Provided hygiene and skin hydration care with a solution of water and mild soap
and applied moisturizer. Encouraged active patient mobilization. The patient was cooperative and
without complaints. Informed the patient and their family about the importance of preventive
care and instructed them on the signs of pressure injury alert. Reassessed the patient after
interventions in 2 hours, according to the care plan. Name of the professional, position, and
Guyana Nursing Registration.
References
1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific
Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference
Guide. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.
2. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023
 Attachment L:
GIVING AND REMOVING A BEDPAN
Related Course(s) Health assessment
Nursing process
Theoretical content Giving and removing a bedpan
Definition A bedpan is an object used for the toileting of a bedridden patient in a health care
facility, usually made of a metal, or plastic receptacle. Women usually use a
bedpan for bowel movements and urinating. A man uses a bedpan for a bowel
movement but may prefer a urinal when he urinates.
Rationale  A person may need to use a bedpan or urinal because he cannot walk to
the bathroom. He may have an illness, injury, or surgery that makes him
unable to walk.
 A person should regularly urinate and have bowel movements to help
prevent other health problems from occurring.
 There may be only a small amount of time between the urge to urinate
and urination.
 The caregiver must be quick to respond to the toileting needs of the
person in bed.
Principles  Some factors can inhibit the effective use of a bed pan, including:
environment, privacy, type of injury, medication, odors, sounds, and
education.
 There are several different kinds of bedpans and urinals available. Some
are metal and others are hard plastic.
 There are bedpans for people who cannot raise their hips. This may
include people in body casts or with hip fractures.
 Some urinals are made for men and others are made for women. Some
urinals are reusable and others are thrown away after each use. You can
buy bedpans and urinals at medical supply and drug stores.
 For people recovering from injuries or surgery, a portable or bedside
commode may be a good option. This is a light weight metal or plastic
chair with a removable toilet bowl.
Requisities  Bedpan and cover
 Toilet paper
 Hand-cleansing wipes
 Soap
 Water
 Towel
 Disposable glove and apron
 Mackintosh and draw-sheet

Figure 1 - Requisites on a tray for giving and removing bedpan

Procedures:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Introduce yourself.
4. Explain procedure to patient to gain consent.
5. Close curtains around bed and close the door to the room, if possible.
6. Assess the patient’s ability to assist with the procedure.
7. Encourage the patient to assist with care to promote independence.
8. Put on the gloves.
9. Leave patient in a comfortable position.
10. Return the proper place for personal belongings after drying up.
11. Replace all instruments.
12. Remove gloves.
13. Remove additional PPE, if used.
14. Cover the sheets beneath the patient with a waterproof protector.
15. Fill the bedpan with very warm water and let the water sit for several minutes, then empty it out
and dry off the bedpan.
16. Fill the bedpan with just enough water to cover the bottom.
17. Instruct the patient to remove clothing from the bottom half of his or her body. Assist the patient
if he or she is unable to do this alone. If the patient is wearing a gown with an opening in the back,
you can leave the gown on. If the gown has no opening, you will need to lift it above the patient's
waist.
18. Pull the top sheet or blanket back.
19. Lower the bed as far as possible to reduce the risk of injury if the patient falls during the
procedure.
20. Lower the head of the bed.
21. Instruct the patient to lie in the supine position. The knees should be bent and the feet should be
flat on the mattress.
22. Set the clean bedpan directly next to the patient's hips on the side of the bed.
23. Help the patient shift away from the bed. If the patient does not have the strength to do so, you
will need to turn the patient to his or her side, instead.
24. If the patient can lift his or her hips:
25. Instruct your patient to raise his or her hips on the count of three.
26. Support the patient by placing your hand beneath the lower back. Do not do any serious lifting
with this hand. You should only provide light support.

 If the patient cannot lift his or her hips:

 Gently turn the patient to the side facing away from you. Work carefully to prevent
the patient from rolling onto his or her stomach or off the bed.
 Slide the bedpan beneath the patient's buttocks with the curved edge of the bedpan
facing the back.

 If the patient can lift his or her hips:

 Slide the bedpan underneath the buttocks and instruct the patient to ease down onto
it, using your support hand to guide him or her.

 If the patient cannot lift his or her hips:

 Slide the bedpan directly next to the patient's buttocks. Keep the open end pointing
toward the patient's feet.
 Gently roll the patient back onto his or her back and over the bedpan. Hold the
bedpan close to the patient's body as you work.

27. Carefully raise the head of the bed, bringing the patient's body up into a more natural toileting
position.
28. Ask the patient to spread his or her legs slightly so that you can verify proper bedpan placement.
29. Make sure that the bedpan is positioned securely beneath the entire area of the buttocks.
30. Place toilet paper within the patient's reach. Let the patient know that it's there.
31. Provide sanitary wipes for the patient's hands.
32. Keep a signal cord, bell, or similar device near the patient and instruct the patient to ring the
signal when finished.
33. Give the patient privacy as he or she uses the bedpan. Let him or her know you will be back to
check in a few minutes, but instruct the patient to ring for you if he or she finishes before then.
Do not leave the patient if doing so would be unsafe.
34. Wash your hands and put on new gloves.
35. Return to the patient's side as soon as you receive a signal from him or her.
36. Bring a basin of warm water, soap, toilet paper, and sanitary cleansing cloths with you when you
return.
37. If the patient does not signal to you within five to ten minutes, check on his or her progress.
Continue checking every few minutes.
38. Lower the head of the bed as much as possible without making the patient uncomfortable.
39. If the patient lifted himself or herself onto the bedpan, the patient should also lift himself or
herself off. If you need to turn the patient onto the bedpan, you will need to turn the patient off.

 If the patient can lift himself or herself:

 Ask the patient to bend his or her knees.
 Instruct the patient to raise his or her lower half. Place your hand beneath the lower
back to offer gentle support.

 If the patient cannot lift himself or herself:

 Hold the bedpan flat on the bed.
 Simultaneously roll the patient to the side facing away from you.

40. Slide the bedpan from its current position and allow the patient to rest.
41. Cover the bedpan with a towel and set it aside for the time being.
42. Determine whether or not the patient was able to clean himself or herself. If not, you will need to
clean the patient.
43. Clean the patient's hands with a wet, soapy washcloth or sanitary wipes.
44. Clean the patient's bottom half with toilet paper. For female patients in particular, wipe from front
to back to reduce the risk of contaminating the urinary tract with bacteria from the rectum.
45. Remove the waterproof covering or towel.
46. Change the bed linens and the patient's gown or clothing immediately if a spill or other
contamination occurs.
47. If there is an odor in the room, consider spraying an air freshener.
48. Help the patient shift back into a comfortable resting position.
49. If necessary, raise or lower the entire bed or the head of the bed to keep the patient more
comfortable.
50. Take the bedpan to the bathroom and check its contents. Look for anything unusual, like streaks
of red, black, or green, as well as mucus or diarrhea.
51. If necessary, measure and record the output.
52. Empty the contents of the bedpan into the toilet and flush them away.
53. Flush out the contents of the bedpan with cold water. Pour this water into the toilet.
54. Scrub the bedpan with cold, soapy water and a toilet brush. Rinse it with additional cold water,
and empty the water into the toilet.
55. Dry the bedpan and return it to its proper storage position when done.
56. Remove your gloves.
57. Replace all instruments.
58. Remove gloves.
59. Remove additional PPE, if used.
60. Perform hand hygiene.
61. Document the care provided.
Nursing documentation
Date and Time: Performed the bedpan placement and removal procedure on a patient with
physical limitations. Assisted the patient to change position on the bed and to be positioned
comfortably and safely. Placed the bedpan under the patient's buttocks. After the procedure,
performed perineal hygiene with wet wipes. Name of the professional, position, and Guyana
Nursing Registration.
References
1. Lynn, P.B. (2022) Taylor's Clinical Nursing Skills (6th Ed.). Wolters Kluer.
2. Potter, P.A.; Perry, A.G.; Stockert, P.; Hall, A. (2022) Fundamentals of Nursing (11th Ed.). Elsevier.
3. Taylor, C.R.; Lynn, P.B.; Bartlett, J.L (2022) Fundamentals of Nursing: The Art and Science of
Person-Centered Care (10th Ed.). Wolters Kluer.
Elaboration Rochelle Allicock
Karina Dal Sasso Mendes
Fernanda Raphael Escobar Gimenes
Carla Aparecida Arena Ventura
Lucila Castanheira Nascimento
Revision Karina Dal Sasso Mendes
April/2023