8.5 Bedmaking, Linen Handling, and Pressure-Redistribution Surfaces

8.5 Bedmaking, Linen Handling, and Pressure-Redistribution Surfaces

Core Clinical Mandate: Duty E: Provide Assistance with Activities of Daily Living carries 19% of the Oklahoma 8607 written examination — 13 questions, the largest single block on the test. Two of its sub-topics are "Make an occupied or unoccupied bed" and "Maintain a pressure mattress." Both bedmaking variants are listed separately on the published Nurse Aide Skills List, which means either can be drawn as one of the three randomly selected skills in your seven-skill clinical scenario.

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Why Bedmaking Is a Clinical Skill

A bed is the surface a dependent resident occupies for eighteen or more hours a day. Three clinical consequences follow directly from how it is made:

1. Pressure injury risk. A wrinkled bottom sheet is a ridge. Under an immobile resident, that ridge concentrates the resident's body weight onto a narrow line of tissue over the sacrum, trochanter, or heel, raising interface pressure above capillary closing pressure and producing exactly the ischemia described in Section 8.4.
2. Skin tears and shear. Dragging a resident across a rough, damp, or crumb-covered sheet strips fragile geriatric epidermis.
3. Infection transmission. Linen carries skin scales, wound drainage, urine, and feces. Handling it carelessly moves organisms from one resident to the environment, to your uniform, and onto the next resident.

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Universal Linen-Handling Rules

These rules apply to every bed you touch and are heavily tested:

• Never shake linen — clean or soiled. Shaking aerosolizes skin scales, lint, and microorganisms into room air, where they settle on every surface. Unfold and place linen gently.
• Hold all linen away from your uniform. Your uniform is a transmission vehicle you carry to the next resident.
• Never place linen on the floor — not clean linen, not soiled linen, not for a second.
• Never place soiled linen on furniture, on the overbed table, on a chair, or on another resident's bed.
• Carry only what you need into the room. Linen brought into a resident's room and not used is considered contaminated; it cannot be returned to the clean linen cart and must be placed in the soiled hamper.
• Roll soiled linen inward, with the dirtiest surface folded to the inside, and place it directly into the designated linen hamper or bag.
• Wear gloves whenever linen is soiled with blood or body fluids, and perform hand hygiene after removing them.
• Do not overfill hampers, and keep the hamper outside the room or just inside the door per facility policy rather than in the hallway blocking traffic.

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Making an Unoccupied Bed

An unoccupied bed is made while the resident is up in a chair, at therapy, or in the shower.

1. Perform hand hygiene and gather all linen in the order of use, so the first item needed sits on top of the stack.
2. Raise the bed to a comfortable working height to protect your lumbar spine, and lower the side rails on the working side.
3. Remove soiled linen by loosening it around the bed and rolling each piece inward without shaking. Place it directly in the hamper.
4. Perform hand hygiene again and, if gloves were worn, remove them first.
5. Apply the bottom sheet, centering the fold on the mattress. Work one entire side of the bed before moving to the other — walking around the bed repeatedly wastes time and, on the skills exam, wastes your 60 minutes.
6. Miter the corners so the bottom sheet stays taut, and tuck the sides tightly under the mattress.
7. Add the draw sheet or lift sheet if the resident's plan calls for one, positioning it to extend from above the shoulders to below the hips, and tuck it smooth and tight.
8. Apply the top sheet, blanket, and bedspread, then make a toe pleat — a small fold of linen across the foot of the bed — to relieve pressure on the toes and prevent footdrop from tight bedding.
9. Change the pillowcase without tucking the pillow under your chin, and place the open end away from the door.
10. Lower the bed to its lowest position, attach the call light within reach, and perform hand hygiene.

Two Named Variants

• Closed bed: The bedspread is pulled all the way up over the pillow. This is the standard made bed for a room whose resident is up and about.
• Open (fan-folded) bed: The top linens are folded back to the foot so the resident can get in easily — used when the resident is returning to bed shortly.

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Making an Occupied Bed

An occupied bed is made when the resident cannot get out of bed. This is the harder skill and the one more likely to appear on the clinical exam.

[!CRITICAL] Never Leave the Resident Unattended on an Unprotected Side Throughout an occupied bed change, the side rail on the far side must be raised while the resident is turned toward it, and the aide must never turn away from or leave the bedside. Turning your back to reach for linen while a resident is rolled to the edge of a mattress is how residents fall out of bed during this skill.

1. Perform hand hygiene, identify the resident, explain the procedure, and provide privacy by closing the door and pulling the privacy curtain fully around the bed.
2. Raise the bed to working height and lower the head of the bed as flat as the resident can tolerate.
3. Cover the resident with a bath blanket for warmth and dignity, then remove the top sheet from underneath the blanket without exposing the resident.
4. Raise the side rail on the far side. Assist the resident to turn onto their side facing that raised rail.
5. Loosen the soiled bottom linen on your side and fan-fold or roll it inward as close to the resident's back as possible, dirtiest surface inward.
6. Place the clean bottom sheet on your half, centered, with the excess fan-folded against the roll of soiled linen. Miter the corner, tuck the side tightly, and smooth every wrinkle.
7. Add the clean draw sheet on your half, tucking and fan-folding the remainder against the roll.
8. Assist the resident to roll over the linen hump toward you, warning them first that they will feel a ridge under them. Now raise the rail on your side before moving to the other side of the bed.
9. On the second side, remove the soiled linen into the hamper, pull the clean linen through, miter, tuck, and smooth completely.
10. Reposition the resident supine in good alignment, replace the top sheet over the bath blanket, and pull the blanket out from underneath.
11. Make a toe pleat, change the pillowcase, and reposition the pillow.
12. Lower the bed to its lowest position, restore rails to their ordered status, place the call light within reach on the unaffected side, and perform hand hygiene.

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Maintaining a Pressure-Redistribution Mattress

Specialty support surfaces are prescribed for residents at moderate-to-high pressure injury risk. The nurse aide does not select the surface, but the aide keeps it working.

Rules That Are Frequently Tested

• Use only a single, loosely applied sheet over a specialty surface. Stacking incontinence pads, folded blankets, and multiple draw sheets creates a rigid layer that transmits pressure straight through the mattress and cancels the therapy it provides.
• Never tuck linens tightly over an alternating-pressure mattress, which restricts cell inflation.
• A pressure-redistribution mattress does not replace repositioning. The residents' repositioning schedule in the plan of care continues unchanged.
• Report immediately if the pump is silent, unplugged, alarming, or if the resident "bottoms out" — meaning you can feel the mattress base through the surface with your hand under the resident's sacrum.
• Do not use pins, and do not place sharp objects on an air surface; a puncture deflates the cells.