List 1.
Coding system.
| Standard Bed, top side rails up |
| 1. Subject Number |
| INGRESS |
| 2. What does the patient use for support when reaching the bed? |
| Hands—Hand flat on the mattress |
| Knuckles—clenched fist on the bed? |
| Fingers—Hand outstretched? |
| 3. Nurse assist patient? |
| No-—Unassisted |
| Yes—Assisted by 1 (1) or (2) RNs? |
| 4. Move around side rail? Does the patient lift him/herself around the side rail? |
| Yes |
| No |
| 5. Leg effort (Assist) Is the patient able to lift his/her legs onto the bed without straining? |
| Yes—Legs lifted easily |
| No—Patient had difficulty in lifting legs onto the bed |
| (Assist)—if yes, were the legs lifted onto the bed by the RN? Yes/no? |
| 6. Does the patient move up in the bed (That is pushing with hands on the mattress to lift buttocks, and pushing with heals to “bounce” up bed? (Number tries) |
| If yes, (Number of tries) |
| No |
| IN BED MOVEMENT Lying Down |
| 7. Body Position Lying |
| Back |
| Side |
| 8. Holding side rail? (# of hands) |
| Yes (1 or 2 hands) |
| No |
| 9. Location in bed? When the patient lies down in the bed, is his/her head in the appropriate position so that the head is on the pillow? |
| Appropriate—yes |
| Inappropriate—no |
| If no, note if the patients is low in the bed, or too high (ie, Ss head on the head of the bed |
| 10. Uses side rail to turn? (Number of hands)? |
| Yes (one or two hands?) |
| No |
| EGRESS |
| 11. Does the subject use the rail to pull up into a sitting position? |
| Yes (One or two hands?) |
| No |
| 12. Bounce to move down the bed? (Number of “bounces”) |
| Yes (How many?) |
| No |
| 13. Hold side rail when turning at end of rail? |
| Yes |
| No |
| 14. When the patient I sitting on the side of the bed, are the feet flat on the floor? |
| Yes |
| No, (give details) |
| 15. Assisted to stand? |
| Yes (uses side rail, RN assist or walking aid?) |
| No |
| 16. Does the patient use the side rail to maintain balance when standing? |
| Yes |
| No |
| Standard Bed, side rails down and low bed |
| 1. Subject Number |
| INGRESS |
| 2. What does the patient use for support when reaching the bed? |
| Hands—Hand flat on the mattress |
| Knuckles—clenched fist on the bed? |
| Fingers—Hand outstretched? |
| 3. Nurse assist patient? |
| No-—Unassisted |
| Yes—Assisted by 1 (1) or (2) RNs? |
| 4. Controlled or uncontrolled sit? |
| Controlled—Patient sits on bed in a without loosing balance or muscular control |
| Uncontrolled—Patient “flumps” or falls onto the bed in a sitting position |
| 5. Leg effort (Assist) Is the patient able to lift his/her legs onto the bed without straining? |
| Yes—Legs lifted easily |
| No—Patient had difficulty in lifting legs onto the bed |
| (Assist)—if yes, were the legs lifted onto the bed by the RN? Yes/no? |
| 6. Location in bed? When the patient lies down in the bed, is his/her head in the appropriate position so that s/he head is on the pillow? |
| Appropriate—yes |
| Inappropriate—no |
| If not, note if the patients is low in the bed, or too high (ie head on the head of the bed |
| 7. Does the patient move up in the bed (That is pushing with hands on the mattress to lift buttocks, and pushing with heals to “bounce” up bed? (Number tries) |
| If yes, (Number of tries) |
| No |
| IN BED MOVEMENT |
| 8. Body Position Lying |
| Back |
| Side |
| 9. Pull on mattress to turn? Does the patient pull on the mattress to turn over? |
| Yes |
| No |
| EGRESS |
| 10. Bounce to get out/assisted? (used mattress?) Does the patient lift him/her self across the mattress? |
| Yes (How many bounces?) |
| No |
| 11. When the patient is sitting on the side of the bed, are the feet flat on the floor? |
| Yes |
| No, (give details) |
| 12. Assisted to stand? |
| Yes (give details) |
| No |
| 13. Required assistance when standing? Does the patient require support to maintain balance? |
| Yes |
| No |