Performance Rating Scale

Philippine Women’s University

School of Nursing
Nursing Skills Assessment
Name: ______________________________ Date: _______________

Bedmaking

Critical Elements:
1. Wear gloves as needed.
2. Remove linens one item at a time.
3. Soiled linen should not come into contact with the nurse’s uniform.
4. For patients who are on isolation, place dirty linens on the appropriate disposal bag.
5. For bedmaking, arrange linens according to use.
6. Torn linens should not be used for bedmaking.
7. Linens should not come in contact with the floor.

Learning Objective: Perform bedmaking following the standard procedure.

Remarks
Nursing Action Rationale
Demonstrated Not Demonstrated

1. Refer to medical record, care plan, or Used as a basis for care.

Kardex.

2. Assemble supplies. To save time and energy.

3. Introduce self. To establish a working

relationship.
4. Identify patient.

5. Explain procedure. To have the cooperation of

patient.

6. Perform hand hygiene and don clean To lessen microorganisms

gloves as appropriate. and to protect oneself from
any microbes present in
the bedsheets.
7. Prepare patient
a. Close door/pull privacy curtain. For patient’s privacy.

b. Raise bed to appropriate height For good body mechanics.

and lower side rail on the side
closest to the nurse.

c. Lower head of bed if patient can Patient with dyspnea or

tolerate it. heart condition will not be
able to tolerate the supine
position.
d. Assess patient’s tolerance of
procedure. Be alert for signs of
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discomfort and fatigue. Signs of discomfort and

fatigue must be noted and
8. Occupied bed when present, nurse may
a. Remove spread and blanket discontinue the procedure.
separately and, if soiled, place in
laundry bag; if linens will be To check for any presence
reused, fold neatly and place over of patient’s articles which
back of chair may be found in between
the sheets.
b. Place bath blanket over patient on
top of sheet
To prevent patient from
c. Request patient to hold onto bath getting chilly.
blanket and remove top linens
To secure privacy.
d. Place soiled sheet in laundry bag

e. With assistance from coworker, To prevent spread of

slide mattress to top of bed microorganisms.

f. Position patient to far side of the

bed with the back toward nurse;
adjust pillow for comfort; be sure For patient’s safety.
side rail is up

g. Beginning at head and moving

toward foot, loosen bottom linens;
fan-fold linen, draw sheet,
protective draw sheet, and bottom
sheet, tucking edges of linens
under patient

h. Apply clean linens to bed by first

placing mattress pad (if used); fold
lengthwise, making sure center
crease is in center of bed; likewise,
unfold bottom sheet and place
over mattress pad, hem of bottom
sheet should be placed with rough
edge down and just even with
bottom edge of mattress

i. Miter corners (if flat sheet) at

head of bed; continue to tuck in
sheet alongside toward front,
keeping linens smooth

j. Reach under the patient to pull

out protective draw sheet (if
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used), and smooth out over clean

bottom sheet; tuck in; unfold linen
draw sheet and place center fold
along middle of bed, smooth out
over the protective draw sheet
and tuck in; tuck in folded linens in
center of bed so they are under
patient’s buttocks and torso

k. Keep palms down as linens are

tucked under mattress

l. Raise side rail and assist patient to

roll slowly toward nurse over folds
of linen; go to opposite side of bed
and lower side rail

m. Loosen edges of all soiled linens;

remove by folding into a bundle
and place in laundry bag

n. Spread clean linens, including

protective draw sheet, out over
mattress and smooth out wrinkles;
assist patient to spine position and
position pillow for comfort

o. Milter top corner of bottom sheet,

pulling sheet taut; tuck bottom
sheet under mattress all the way
to foot of feet

p. Smooth out draw sheets; pulling

sheet taut, tuck in protective draw
sheet and then tuck in linen draw
sheet

q. Place top sheet over bath blanket

that is over patient; request
patient to hold top sheet while
nurse removes bath blanket; place
blanket in laundry bag; if blanket is
used, place over sheet and place
spread over blanket; form cuff
with top linens under patient’s
chin

r. Tuck in all linens at foot of bed,

making modified miter corner;
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raise side rail and make opposite

side of bed; make toe pleat by
placing fold either lengthwise
down center of bed or across foot
of bed

s. Change pillowcase: grasp closed

end of pillowcase, turning case
inside out over hand, grasp one
end of pillow with hands in the
case and smooth out wrinkles

9. Unoccupied bed
a. Starting at head of bed, loosen
linens all the way to foot; go to
opposite side of bed, loosen
linens, roll all linens up in ball,
and place in soiled laundry bag;
perform hand hygiene after
handling soiled linens

b. If blanket and spread are to be

reused, fold neatly and place
over back of chair; remove soiled
pillowcase

c. Slide mattress to head of bed

d. If necessary, clean mattress with

cloth moistened with antiseptic
solution and dry thoroughly

e. Begin to make bed standing on

side where lines are placed;
unfold bottom sheet, placing fold
lengthwise down center of bed;
make certain rough edge of hem
lies down away from patient’s
heels and even with edge of
mattress; smooth out sheet over
top edge of mattress and miter
corners; tuck remaining sheet
under mattress all the way to
foot

f. Place draw sheet on bed so that

center fold lies down middle of
bed; if protective draw sheet is to
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be used, place it on first; smooth

out over mattress and tuck in;
keep palms down

g. Place top sheet over bed and

smooth out; place blanket over
top sheet; smooth out; place
spread over blanket and smooth
out; make cuff with top linens

h. Allow for toe pleat; make

modified mitered corner by not
tucking tip of under mattress

i. Move to opposite side of bed and

complete making bed as
described in steps 9e to 9h; pull
linens tight and keep taut as
linens are tucked in

j. Put on clean pillowcase (see step

8s); position pillow at head of
bed; place call light within easy
reach ad lower bed level

k. If patient is to return to bed, fan-

fold top linens down to foot of
bed; make sure cuff at top of
linens is easily accessible to
patient

10. Arrange personal items on bed table

or bedside stand and place within
patient’s easy reach.

11. Leave area neat and clean.

12. Place all soiled linens in proper

receptacle; perform hand hygiene.

13. Assist patient to bed and position for

comfort.

14. Documentation (Bed making does

not need to be recorded. Record
patient’s vital signs, signs and
symptoms only if there are changes).
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15. Report any abnormal findings to

nurse in charge or physician.

Note: Open bed is a type of bed that is made in such a way that is ready to receive a newly
admitted patient. Surgical bed is a type of bed that is made in such a way that it is ready to
receive a post-surgical patient. Top sheet is fan folded. Most hospitals now use fitted bottom
sheets. 9