A full set of raised side rails (two to a bed or four to a bed) is a physical restraint when used solely for the purpose of preventing the patient from getting out of bed.
1. Perform hand hygiene.
2. Determine if the patient has been incontinent or if excess drainage is visible on the linen.
3. Assess restrictions in mobility or positioning of the patient. Explain the procedure to the patient, noting that the patient will be asked to turn over layers of linen.
4. Assess the patient for pain, and premeditate as warranted.
5. Draw the privacy curtain around the bed.
6. Assemble clean linen and a linen bag on the bedside table. Lower the head of the bed, keeping the patient comfortable. Raise the bed to a comfortable working position, and lower the side rail from the side where the nurse is standing.
7. Perform hand hygiene and don gloves.
8. Loosen the top linen at the foot of the bed.
9. Remove the blanket separately. If it is to be reused, fold it into a square and place it over the back of the chair. If the blanket is soiled, fold it into a bundle or square, holding it away from the body, and place it in the linen bag. Avoid shaking or fanning the blanket.
10. Cover the patient with a bath blanket, placing it over the top sheet. Have the patient hold the top edge of the bath blanket, or tuck the blanket under the patient's shoulders. Reach beneath the blanket, and remove the top sheet. Discard the sheet in the linen bag.
11. Assess the location and tension of the patient's medical devices, tubes, and wires. Position them so as to minimize impact to their function and prevent excessive tension on any external medical devices during bed making.
12. Assist the patient to a side-lying position, facing away from the nurse. Encourage use of the side rail to aid in turning. Adjust the pillow under the patient's head.
13. Loosen bottom linens, moving from head to foot. Fanfold the bottom sheet, draw sheet, and any cloth pads toward and under the patient. Tuck the edges of the soiled bottom linen alongside the patient's buttocks, back, and shoulders.
14. Clean, disinfect, and dry the mattress surface, if needed.
15. Apply clean linens to the exposed half of the bed in separate layers. Start with the mattress pad by placing it lengthwise with the center crease in the middle of the bed. Fanfold the layer to the center of the bed alongside the patient. Repeat this process with the bottom sheet and drawsheet.
16. Pull the fitted sheet smoothly over the mattress edges. Allow the edge of the flat sheet to hang a few inches over the mattress edge. Ensure that the lower hem of the bottom sheet lies seam down and even with the bottom edge of the mattress.
17. If the bottom sheet is not fitted, miter the top corner of the bottom sheet at the head of the bed. Face the head of the bed diagonally. Placing hand away from the head of the bed under the top corner of the mattress, lift, and with other hand tuck the edge of the bottom sheet smoothly under the mattress so that it forms a corner around the mattress.
18. Pick the top of the sheet up several inches from the top of the mattress. Lift the sheet and lay it on top of the mattress to form a triangular fold, with the lower base of the triangle even with the mattress side edges.
19. Tuck the lower edge of the sheet, which is hanging free under the mattress. Hold the portion of the sheet covering the side of the mattress in place with one hand. With the other hand, pick up the triangular linen fold and bring it down over the side of the mattress. Tuck with palms down, without pulling the triangular fold. Tuck this portion under the mattress.
20. Tuck the remaining portion of the sheet under the mattress, moving toward the foot of the bed. Keep linen smooth.
21. Place the open draw sheet along the middle of the bed lengthwise, and tuck the remainder under the patient's buttocks and torso. Place a waterproof pad under the draw sheet, if needed.
22. Raise the side rail, and ask the patient to turn toward the nurse; assist as needed. Tell the patient that he or she will be rolling over layers of linen. Advise the patient to roll across the linens without lifting the body over them. Ensure that the patient turns slowly.
23. Move to the opposite side of the bed; lower the side rail. Assist the patient with positioning on the other side across the folds of linen.
24. Loosen the edges of soiled linen from under the mattress.
25. Remove soiled linen by folding it into a bundle or square, holding it away from the body, and placing it in the linen bag. Avoid shaking or fanning the linen.
26. Clean, disinfect, and dry the other half of the mattress, as needed.
27. Pull the clean, fan folded linen over the edge of the mattress from head to foot of the bed.
28. Assist the patient with rolling back into a supine position. Pull the fitted sheet over the mattress ends.
29. Miter the top corner of the bottom flat sheet using the same procedure for mitering the top corner of a no fitted bottom sheet.
30. Facing the side of the bed, grasp the remaining edge of the bottom flat sheet. Lean back, keep back straight, and pull while tucking the excess linen under the mattress, from head to foot of the bed.
31. Smooth the fan folded draw sheet over the bottom sheet. Also smooth out waterproof pad, if used.
32. Place the top sheet over the patient with vertical centerfold lengthwise down the middle of the bed. Open the sheet out from head to foot and unfold over the patient. Ensure that the top edge of the sheet is even with the top edge of the mattress.
33. Ask the patient to hold the clean top sheet. Remove the bath blanket and discard it in the linen bag.
34. Place a clean or reused bed blanket on the bed over the patient. Ensure that the top edge is parallel with the top edge of the sheet and is a few inches from the top sheet's edge.
35. Make a cuff by turning the edge of the top sheet down over the top edge of the blanket.
36. Make a horizontal toe pleat; stand at the foot of the bed, and fanfold the sheet and blanket a few inches across the bed.
37. Pull the sheet and blanket up from the bottom to make a fold several inches from the bottom edge of the mattress.
38. Tuck the remaining portion of the sheet and blanket under the foot of the mattress. Tuck the top sheet and blanket together. Be sure the toe pleats are not pulled out.
39. Make a modified mitered corner with the top sheet and blanket. After making a triangular fold, do not tuck the tip of the triangle. Be aware that tucking the top sheet and blanket tightly under the mattress at the foot of the bed can cause rubbing of the patient's feet on the sheets and result in pressure ulcers on the patient's toes and heels.
40. Return the side rail to it its original position.
41. Go to other side of the bed. Spread the sheet and blanket out evenly. Repeat the sheet folding and tucking procedure, starting with the horizontal toe pleat.
42. Apply a clean pillowcase over the pillow.
43. Place the call light within the patient's reach on the bed rail or pillow, and return the bed to its lowest position.
44. Organize the patient's room.
45. Discard supplies, remove gloves, and perform hand hygiene.
46. Document the procedure in the patient's record.
A full set of raised side rails (two to a bed or four to a bed) is a physical restraint when used solely for the purpose of preventing the patient from getting out of bed.
1. Perform hand hygiene.
2. Determine if the patient has been incontinent or if excess drainage is visible on the linen.
3. Assess restrictions in mobility or positioning of the patient. Explain the procedure to the patient, noting that the patient will be asked to turn over layers of linen.
4. Assess the patient for pain, and premeditate as warranted.
5. Draw the privacy curtain around the bed.
6. Assemble clean linen and a linen bag on the bedside table. Lower the head of the bed, keeping the patient comfortable. Raise the bed to a comfortable working position, and lower the side rail from the side where the nurse is standing.
7. Perform hand hygiene and don gloves.
8. Loosen the top linen at the foot of the bed.
9. Remove the blanket separately. If it is to be reused, fold it into a square and place it over the back of the chair. If the blanket is soiled, fold it into a bundle or square, holding it away from the body, and place it in the linen bag. Avoid shaking or fanning the blanket.
10. Cover the patient with a bath blanket, placing it over the top sheet. Have the patient hold the top edge of the bath blanket, or tuck the blanket under the patient's shoulders. Reach beneath the blanket, and remove the top sheet. Discard the sheet in the linen bag.
11. Assess the location and tension of the patient's medical devices, tubes, and wires. Position them so as to minimize impact to their function and prevent excessive tension on any external medical devices during bed making.
12. Assist the patient to a side-lying position, facing away from the nurse. Encourage use of the side rail to aid in turning. Adjust the pillow under the patient's head.
13. Loosen bottom linens, moving from head to foot. Fanfold the bottom sheet, draw sheet, and any cloth pads toward and under the patient. Tuck the edges of the soiled bottom linen alongside the patient's buttocks, back, and shoulders.
14. Clean, disinfect, and dry the mattress surface, if needed.
15. Apply clean linens to the exposed half of the bed in separate layers. Start with the mattress pad by placing it lengthwise with the center crease in the middle of the bed. Fanfold the layer to the center of the bed alongside the patient. Repeat this process with the bottom sheet and drawsheet.
16. Pull the fitted sheet smoothly over the mattress edges. Allow the edge of the flat sheet to hang a few inches over the mattress edge. Ensure that the lower hem of the bottom sheet lies seam down and even with the bottom edge of the mattress.
17. If the bottom sheet is not fitted, miter the top corner of the bottom sheet at the head of the bed. Face the head of the bed diagonally. Placing hand away from the head of the bed under the top corner of the mattress, lift, and with other hand tuck the edge of the bottom sheet smoothly under the mattress so that it forms a corner around the mattress.
18. Pick the top of the sheet up several inches from the top of the mattress. Lift the sheet and lay it on top of the mattress to form a triangular fold, with the lower base of the triangle even with the mattress side edges.
19. Tuck the lower edge of the sheet, which is hanging free under the mattress. Hold the portion of the sheet covering the side of the mattress in place with one hand. With the other hand, pick up the triangular linen fold and bring it down over the side of the mattress. Tuck with palms down, without pulling the triangular fold. Tuck this portion under the mattress.
20. Tuck the remaining portion of the sheet under the mattress, moving toward the foot of the bed. Keep linen smooth.
21. Place the open draw sheet along the middle of the bed lengthwise, and tuck the remainder under the patient's buttocks and torso. Place a waterproof pad under the draw sheet, if needed.
22. Raise the side rail, and ask the patient to turn toward the nurse; assist as needed. Tell the patient that he or she will be rolling over layers of linen. Advise the patient to roll across the linens without lifting the body over them. Ensure that the patient turns slowly.
23. Move to the opposite side of the bed; lower the side rail. Assist the patient with positioning on the other side across the folds of linen.
24. Loosen the edges of soiled linen from under the mattress.
25. Remove soiled linen by folding it into a bundle or square, holding it away from the body, and placing it in the linen bag. Avoid shaking or fanning the linen.
26. Clean, disinfect, and dry the other half of the mattress, as needed.
27. Pull the clean, fan folded linen over the edge of the mattress from head to foot of the bed.
28. Assist the patient with rolling back into a supine position. Pull the fitted sheet over the mattress ends.
29. Miter the top corner of the bottom flat sheet using the same procedure for mitering the top corner of a no fitted bottom sheet.
30. Facing the side of the bed, grasp the remaining edge of the bottom flat sheet. Lean back, keep back straight, and pull while tucking the excess linen under the mattress, from head to foot of the bed.
31. Smooth the fan folded draw sheet over the bottom sheet. Also smooth out waterproof pad, if used.
32. Place the top sheet over the patient with vertical centerfold lengthwise down the middle of the bed. Open the sheet out from head to foot and unfold over the patient. Ensure that the top edge of the sheet is even with the top edge of the mattress.
33. Ask the patient to hold the clean top sheet. Remove the bath blanket and discard it in the linen bag.
34. Place a clean or reused bed blanket on the bed over the patient. Ensure that the top edge is parallel with the top edge of the sheet and is a few inches from the top sheet's edge.
35. Make a cuff by turning the edge of the top sheet down over the top edge of the blanket.
36. Make a horizontal toe pleat; stand at the foot of the bed, and fanfold the sheet and blanket a few inches across the bed.
37. Pull the sheet and blanket up from the bottom to make a fold several inches from the bottom edge of the mattress.
38. Tuck the remaining portion of the sheet and blanket under the foot of the mattress. Tuck the top sheet and blanket together. Be sure the toe pleats are not pulled out.
39. Make a modified mitered corner with the top sheet and blanket. After making a triangular fold, do not tuck the tip of the triangle. Be aware that tucking the top sheet and blanket tightly under the mattress at the foot of the bed can cause rubbing of the patient's feet on the sheets and result in pressure ulcers on the patient's toes and heels.
40. Return the side rail to it its original position.
41. Go to other side of the bed. Spread the sheet and blanket out evenly. Repeat the sheet folding and tucking procedure, starting with the horizontal toe pleat.
42. Apply a clean pillowcase over the pillow.
43. Place the call light within the patient's reach on the bed rail or pillow, and return the bed to its lowest position.
44. Organize the patient's room.
45. Discard supplies, remove gloves, and perform hand hygiene.
46. Document the procedure in the patient's record.
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