Nurse Assisting
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Chapter 16 Expanded Skills

Click on the skills to review expanded skills discussed in this chapter.

Starting-Up Steps

  1. Knock before entering, identify the client, and introduce yourself.
  2. Complete hand hygiene.
  3. Provide for privacy.
  4. Explain to the client what you will be doing before you start doing it.
  5. Assemble your supplies.
  6. Ensure that the bed is at a good working height and is locked; or, if the bed is not in use, you are in an ergonomically correct position to assist the client.

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Transferring an Ambulatory Bariatric Client

When: The bariatric client may require help to get out of bed in the morning after waking; before meals, activities, and social outings; or as otherwise requested.

Why: The client should be out of bed as much as tolerated or possible to increase their mobility and social interaction. At least two nursing assistants should assist the ambulatory bariatric client, as indicated on the care plan or ISP.

What: Supplies needed for this skill include:

  • Bariatric-approved walker
  • Bariatric-approved, extra-wide wheelchair
  • Shoes or nonskid slipper socks
  • Extra-large gait belt, or two standard gait belts fastened together
  • Top sheet or blanket, replacing the client’s draw sheet

How:

  1. Complete your starting-up steps.
  2. Verify the client’s level of assistance as listed on the care plan. Obtain extra help as needed to transfer the client.
  3. Position the wheelchair parallel to the bed, at the head and slightly away from the side of the bed. Lock the brakes on the wheelchair. If the client is lying under the bed linens, fanfold the top linens to the foot of the bed.
  4. Two nursing assistants stand on the same side of the bed as the wheelchair, facing the client. The third nursing assistant stands on the opposite side of the bed, also facing the client. More nursing assistants may be needed, depending on the level of care the client needs.
  5. Raise the side rail on the side of the bed closest to the wheelchair.
  6. Ask the client to reach over herself, grab on to the side rail, and assist in rolling onto their side on the count of three.
  7. On the count of three, the two nursing assistants grasp and pull the top sheet or blanket that is already beneath the client toward the bed rail, one responsible for the lower half of the client, the other for the upper half of the client.
  8. Drape the top sheet or blanket back across the bed, off of the client.
  9. Instruct the client to help with the next movement by placing their hands at their sides flat on the bed, or by grabbing the side rail, and pushing herself upward to a sitting position on the count of three. You may also raise the head of the bed to assist with this step, if it is not too uncomfortable for the client.
  10. On the count of three, the two nursing assistants facing the client assist them to dangle. The nursing assistant on the other side of the bed should support the back of the client so that they remain in a sitting position during dangling. The client’s feet should be flat on the floor. The first nursing assistant facing the client applies a gait belt. The second nursing assistant puts the client’s shoes or nonskid slipper socks on their feet.
  11. After the client is stable, and the gait belt and shoes securely fastened, the nursing assistant behind the client walks around the bed, obtains the walker, and positions it, holding it steady in front of the client during the transfer.
  12. Instruct the client to help during the next movement by placing their hands at their sides flat on the bed and pushing their body upward off of the bed to a standing position on the count of three.
  13. The nursing assistant closest to the wheelchair places their right foot on the outside of the client’s right foot and places their right hand under the client’s right arm to grasp the gait belt. The second nursing assistant stands with their left foot on the outside of the client’s left foot and places their left hand under the client’s left arm to grasp the gait belt. Both nursing assistants assume a wide base of support, bending at the knees.
  14. On the count of three, assist the client to a standing position. Instruct the client to grab on to the walker and steady herself so that their weight is on the walker, not on the nursing assistants.
  15. Instruct the client to turn, using the walker for support and stabilization, until they are standing over the seat of the wheelchair and the back of their legs are touching the seat.
  16. Instruct the client to release the walker, one hand at a time, first grasping one armrest of the wheelchair and then the other. On the count of three, assist the client to a seated position in the wheelchair.
  17. Ensure that the client’s hips and buttocks are against the back of the wheelchair and that they are properly aligned. If not properly aligned, encourage the client to move their buttocks toward the back of the chair, using the armrests for leverage.
  18. Remove the gait belt. Place the leg rests on the wheelchair if indicated on the care plan and position the client’s legs appropriately. Two nursing assistants per leg lift each leg up onto the leg rests of the wheelchair. Ensure proper body mechanics while moving the client’s legs.
  19. Complete your finishing-up steps.

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Transferring a Non-Weight-Bearing Bariatric Client With a Mechanical Lift

When: A bariatric mechanical lift is used for all transfers of bariatric clients, as indicated on the client’s care plan or ISP.

Why: A bariatric lift is required for clients who are morbidly obese and who are unable to bear weight. Use of the bariatric lift reduces the risk of injury to the client and the nursing assistants during transfers.

What: Supplies needed for this skill include:

  • Bariatric-approved mechanical lift
  • Bariatric-approved lift sling
  • Bariatric-approved, extra-wide wheelchair
  • Top sheet or blanket, replacing the client’s draw sheet

How:

  1. Complete your starting-up steps.
  2. Verify the client’s level of assistance as listed on the care plan.
    1. Obtain extra help as needed to transfer the client.
  3. Place the wheelchair in an area of the room that is unobstructed.
  4. Lock the brakes on the wheelchair.
  5. If the client is lying under the bed linens, fanfold the top linens to the foot of the bed.
  6. Two nursing assistants stand on one side of the bed facing the client. Two other nursing assistants stand on the opposite side of the bed facing the client.
  7. Raise the side rails on both sides of the bed.
  8. Ask the client to reach over herself, grab on to side rail, and assist in rolling onto their side on the count of three.
    1. Use positioning rails if available in lieu of side rails.
  9. On the count of three, two nursing assistants grasp and pull the top sheet or blanket that is already beneath the client toward themselves; one nursing assistant is responsible for the client’s lower body, the other for the upper body.
  10. One of the nursing assistants on the opposite side of the bed centers the lift sling on the exposed half of the mattress, positioned from the top of the client’s shoulders to beneath their buttocks, with the sling handles away from their skin. The fold of the sling should be parallel to the sides. Roll the top layer of the sling up close to the client’s torso and tuck it under her.
  11. On the count of three, using the top sheet or blanket, the first two nursing assistants help the client return to the supine position.
  12. Ask the client to reach across the other side of their body and grasp the side rail and assist in rolling onto their other side on the count of three.
  13. On the count of three, the second set of nursing assistants grasp and pull the top sheet or blanket toward themselves, one responsible for the lower half of the client, the other for the upper half of the client.
  14. One of the nursing assistants on the opposite side of the bed unrolls the sling so that it is completely beneath the client.
  15. On the count of three, using the top sheet or blanket, the second two nursing assistants help the client return to the supine position.
    1. Ensure that the sling is proportionately aligned on each side of the client and spans their length from the top of their shoulders to below their buttocks.
    2. The top sheet or blanket remains under the client to facilitate sling removal and repositioning when they are transferred back to bed.
  16. Lower the side rails.
  17. Position the mechanical lift boom over the bed across the client’s chest.
    1. The legs of the lift are under the bed.
  18. Lower the boom with the remote control pendant as close to the client’s chest as possible to place the sling loops easily on the boom hooks.
  19. Attach the sling loops that are closest to the client’s head to the top sling hook.
    1. Place the top sling loops on the upper bar, and the lower loops on the lower bar.
    2. The bariatric boom may have a spreader bar to accommodate the excess weight.
    3. There may be a third hook in the center of the boom. If available, attach a sling loop to this hook also in order to more evenly distribute the weight.
    4. Always follow specific manufacturer’s directives when operating mechanical lifts; brand directives and sling types may vary.
  20. Crisscross the lower sling straps between the client’s thighs. Attach the lower sling loops to the bottom sling hooks.
    1. Ensure the top loops are the same length or color (these are normally color coded), or that the loops used on the top are shorter than the lower loops.
    2. Instruct the client to place their hands across their abdomen and relax during the ­transfer. Assist the client if they are unable.
  21. Using the remote control pendant, one nursing assistant raises the boom until the client’s buttocks are no longer touching the bed. Another nursing assistant takes one of the ­client’s legs, and another takes the opposite leg.
  22. The first assistant moves the mechanical lift back so that the client is no longer over the top of the bed.
    1. While moving away from the bed, but before the client clears the surface, use the remote control pendant to spread apart the legs of the base to stabilize and prevent the lift from tipping.
  23. The two nursing assistants responsible for the client’s legs turn the client so that they are facing the lift, making sure not to bump their feet against it.
  24. After Step 23 is complete, one nursing assistant can aid the first in maneuvering the mechanical lift, while the other can aid the nursing assistant positioning the client in the chair.
  25. The first nursing assistant moves the lift so that the client is positioned above the wheelchair. The fourth nursing assistant positions herself behind the client and, using the sling handles, aids in positioning the client over the wheelchair.
  26. Once the client is positioned over the wheelchair, the first nursing assistant lowers the boom with the remote control pendant until the client is comfortably seated in the wheelchair.
    1. During the movement, the first nursing assistant monitors the boom so that it does not hit the client’s head.
    2. The third or fourth nursing assistant ensures that the client’s hips and buttocks are against the back of the wheelchair and that they are properly aligned by manipulating the handles on the back of the sling.
  27. Remove the sling loops from the sling attachment hooks, and tuck the sling behind the client in accordance with HIPAA regulations, as per your facility protocol.
    1. Place the leg rests on the wheelchair if indicated on the care plan and position the client’s legs appropriately.
    2. Ensure proper body mechanics while moving the client’s legs. You may have to use two nursing assistants to lift each leg up on to the leg rests of the wheelchair.
  28. Complete your finishing-up steps.
  29. Remove the mechanical lift machine from the client’s room and place it in the designated storage area.

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Transporting the Client via Wheelchair

When: The client is transported when requested; when going to activities, appointments, and meals; during transfers; or during discharges.

Why: The client may need assistance traveling by wheelchair to the desired location if they are unable to propel the wheelchair independently.

What: Supplies needed for this skill include:

  • Wheelchair
  • Wheelchair leg rests

How:

  1. Complete your starting-up steps.
  2. Unlock the wheelchair brakes. Wheel the client away from the bed.
  3. Position the leg rests out to the side of the wheelchair, so that the metal pegs on the wheelchair frame are in line with the bracket on the leg rest. Insert the leg rest into the metal pegs on the wheelchair frame.
  4. Lift the client’s leg and foot. Without bumping the client’s feet or legs, swing the leg rest into a locked position. You will hear it click into place.
  5. Push the calf pad down, into place. Push the footrest down, into place. Place the client’s foot and leg on top of the leg rest.
  6. Reposition the leg rest as needed by pulling down on the adjustment bar and moving the leg rest up or down to a comfortable position for the client. Some wheelchairs do not have this feature.
  7. Repeat Steps 3–6 for the opposite leg rest.
  8. Apply any alarms, positioning devices, reminders, or restraints as indicated on the care plan.
  9. Encourage the client to keep their elbows on top of the armrests to avoid bumping injuries during transport.
  10. Let the client know when you are starting to transport.
  11. Push the wheelchair by the handles only in a forward direction; never pull the client backward.
  12. Transport the client to the desired destination.
  13. Complete your finishing-up steps.

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Finishing-Up Steps

  1. Ensure that all of the client’s needs have been met and that the client is positioned as desired.
  2. See to safety. Replace any alarms or positioning devices, as indicated on the care plan or individual service plan. The bed is in the low position and is locked.
  3. Place the call light within easy reach.
  4. Clean and replace equipment, and return supplies to the designated place in the client’s room or facility storage area.
  5. Leave the room clean and in order. Ensure that the bed is made. Remove trash and dirty linens from the room.
  6. Complete hand hygiene.
  7. Report and document, as required by your facility.

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