Positioning and Bed Mobility — Nursing Assistant (CNA)

Objective. The learner will correctly demonstrate repositioning a patient in bed (supine, lateral, Fowler's, Sims', prone where appropriate) and moving a patient up in bed, following a skill checklist without critical errors.

Why Positioning Matters

Every patient who cannot move freely in bed depends on you to protect their skin, lungs, circulation, and comfort. Staying in one position too long compresses tissues over bony prominences, cutting off blood flow and causing pressure injuries (also called pressure ulcers or bedsores). Incorrect positioning can also restrict breathing, cause contractures, and increase fall risk. As a nursing assistant, correct positioning and safe bed mobility are among your most frequently performed—and most regulated—skills.

Body Mechanics: Protect Yourself First

Before touching a patient, protect your own back:

Raise the bed to a working height between your hip and waist. Bending over a low bed is the leading cause of nursing aide back injury.
Lock all four bed wheels before any move. An unlocked bed can roll away mid-transfer.
Keep your feet shoulder-width apart, one foot slightly forward, and bend at the hips and knees—not the waist.
Use a draw sheet or slide sheet to reduce friction and avoid grabbing the patient's skin or limbs.
Ask for a second person whenever a patient weighs more than you can safely move alone, or whenever the patient cannot assist.
Never reach across a bed while twisting; walk around to the far side instead.

Moving a Patient Up in Bed

Patients slide toward the foot of the bed over time. Moving them up restores proper alignment and prevents shearing injuries.

Step-by-step:

1. Explain the procedure to the patient and gain cooperation.

2. Wash hands; apply gloves if linens are soiled.

3. Lock all bed wheels.

4. Raise the bed to working height.

5. Lower the head of the bed to flat (or as low as the patient tolerates).

6. Lower the side rail on your side; keep the far rail up.

7. Position a draw sheet beneath the patient's hips and shoulders.

8. With a co-worker on the other side, both workers roll the edges of the draw sheet close to the patient's body, assume a wide stance, and shift weight from back foot to front foot on a shared count of three.

9. Slide the patient smoothly toward the head of the bed—do not lift unless required by the care plan.

10. Raise the side rail on your side before walking around to the other side.

11. Reposition the patient in the correct ordered position, place pillows appropriately.

12. Lower the bed to its lowest position, check that call light is within reach, and wash hands.

Common Bed Positions

Supine (Flat on Back)

The patient lies on their back with the body in alignment. Place a small pillow under the head and neck. Support the arms at the sides or on pillows. Heels should be off the mattress using a pillow under the calves—heels are a top site for pressure injuries. A trochanter roll (rolled towel or blanket) at the outer thigh prevents external rotation of the hips.

Lateral (Side-Lying)

The patient lies on one side, either left or right. Bend the top knee and hip to 30–45 degrees and place a pillow between the knees to prevent the knees from pressing together. Place a pillow against the patient's back for support and to maintain the position. Keep the dependent (bottom) arm slightly forward to prevent lying directly on it. Avoid positioning on the hip bone—tilt the patient slightly to take pressure off the trochanter. Key bony prominences at risk: lateral malleolus (ankle), medial knee, greater trochanter, shoulder, and ear.

Fowler's Positions

Semi-Fowler's: Head of bed raised 15–30 degrees. Used for patients with mild breathing difficulty or during rest.
Fowler's: Head of bed raised 45–60 degrees. Common after meals to reduce aspiration risk.
High Fowler's: Head of bed raised 60–90 degrees. Used for patients with significant breathing difficulty. Support the arms on pillows to reduce shoulder strain. Place a small pillow at the lower back for lumbar support. Feet should rest flat against a footboard or be supported to prevent foot drop and sliding. Key bony prominences at risk: sacrum and coccyx (shearing from sliding down), heels, elbows.

Sims' Position

The patient lies in a modified left-lateral position at roughly a 45-degree tilt, with the lower arm behind the body and the upper arm and leg flexed and resting on pillows. Used for rectal procedures and enemas, and sometimes to relieve pressure from the sacrum. Key bony prominences at risk: ileum (hip), clavicle, lower shoulder.

Prone (Face-Down)

The patient lies on their abdomen with the head turned to one side. Used only when specifically ordered (e.g., for certain respiratory conditions or to relieve prolonged back pressure). Place a small pillow under the abdomen to protect the spine, and a pillow under the lower legs to elevate the toes off the mattress. Check the patient's airway frequently. Prone is not appropriate for all patients—never position someone prone without an explicit care plan order.

Bony Prominences: Know the High-Risk Sites

Pressure injuries develop fastest where bone is close to skin. Memorize these by position:

Supine: occiput (back of head), shoulder blades, elbows, sacrum/coccyx, heels
Lateral: ear, shoulder, ribs, greater trochanter, medial knee, lateral malleolus
Fowler's: occiput, shoulder blades, sacrum, heels, elbows
Prone: ears, cheeks, clavicle, ribs, iliac crests, knees, toes

Frequency and Documentation

The standard turning schedule for at-risk patients is at least every two hours. Your facility may require more frequent repositioning. Always document the position, the time, the skin condition you observed, and any patient complaints. Report any redness that does not fade within 30 minutes of relieving pressure—this is a Stage 1 pressure injury and must be reported to the nurse immediately.

Critical Safety Checks Before You Leave the Patient

1. Bed is in its lowest position.

2. All side rails are up as required by the care plan.

3. Call light is within reach.

4. Patient is in correct alignment with proper supports.

5. Linens are wrinkle-free (wrinkles cause pressure).

6. Hand hygiene completed and documented.

Key terms10

Bony prominenceAn area where bone lies close to the skin surface and is at high risk for pressure injury when compressed against a surface, such as the sacrum, heels, and greater trochanter.

Pressure injuryLocalized damage to skin and underlying tissue, usually over a bony prominence, caused by sustained pressure or pressure combined with shear; formerly called a pressure ulcer or bedsore.

ShearingA force that occurs when skin stays in place while deeper tissue slides in the opposite direction, commonly caused by a patient sliding down in bed; it tears tiny blood vessels and increases injury risk.

Draw sheetA flat sheet folded and placed crosswise under the patient's hips and torso, used to reposition or transfer a patient with less friction and without grabbing the patient directly.

Fowler's positionA semi-upright bed position in which the head of the bed is elevated; semi-Fowler's is 15–30 degrees, Fowler's is 45–60 degrees, and high Fowler's is 60–90 degrees.

Sims' positionA modified left-lateral position in which the patient tilts approximately 45 degrees, with the lower arm behind the body and the upper arm and leg flexed on pillows; commonly used for rectal procedures.

Lateral positionA side-lying position in which the patient rests on one side with the top knee and hip bent and a pillow placed between the knees to protect bony prominences and maintain alignment.

Trochanter rollA rolled blanket or towel placed along the outer thigh in the supine position to prevent external (outward) rotation of the hip joint.

Body mechanicsThe correct use of body posture, balance, and movement to perform tasks safely, reducing the risk of musculoskeletal injury to the caregiver.

ContracturePermanent shortening and hardening of a muscle or joint caused by prolonged inactivity or improper positioning, resulting in reduced range of motion.

In class: Instructor demonstration on a hospital bed with a training mannequin showing each position, naming bony prominences at risk, and placing pillows and supportive wedges correctly; learners observe and annotate a positioning handout · Step-by-step return demonstration pairs: each learner performs the 'move patient up in bed using a draw sheet' skill on the mannequin while instructor narrates steps and learner verbalizes rationale for each action including locking bed wheels and raising bed to working height · Positioning rotation station: four beds set up around the lab, each with a sign naming the required position; learner pairs rotate through all four, perform the position, place props correctly, and complete a quick self-assessment card before moving to the next station
Materials: Adjustable hospital beds (at least 2), CNA training mannequin, draw sheets, positioning wedges and pillows, incontinence pad/slide sheet, skill checklist aligned to state competency, self-assessment cards
Check: Learner completes the move-up-in-bed skill on the competency checklist with no critical safety errors (e.g., bed not locked, side rail not raised after procedure) and earns a pass on at least 8 of 10 checklist items; instructor signs off

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.