Bariatric Patient Handling: Weight Limits, Team Moves, and Skin Folds

Handling a person of size is not a normal move with more muscle. Standard beds, lifts, chairs and toilets can fail, and the team can get seriously hurt. A leg can weigh more than one person should hold. Breathing can get harder when the person lies flat, and skin can break down in places you would not think to look. Care also goes wrong when staff are awkward or unkind about it. This guide covers how to plan these moves. It builds on Veterans Affairs (VA) safe patient handling guidance. Your facility's policy, the care plan and the maker's manuals come first. The nurse or therapist decides how the person moves, and any equipment needs hands-on training first.

What You Will Be Able to Do

• Explain what bariatric means in patient handling.
• Check every item in the move for weight, width and height.
• Plan a team move with a leader.
• Keep a person's breathing safe during positioning.
• Find skin problems in folds and other unusual places.
• Provide care that protects the person's dignity.

What Bariatric Means

The word comes up a lot, and it has more than one definition. The VA's bariatric handling guidebook defines a bariatric patient as anyone whose weight or size interferes with the ability to give safe, reasonable care. VA handling guidance also flags a higher risk to caregivers for someone who weighs over 300 pounds, is 100 pounds over ideal weight or has a body mass index (BMI) over 40.

A broad definition helps, because weight alone does not tell you what you need. A very tall person may be within a normal BMI and still go over a bed's limit. A short person with wide hips may weigh less than the limit and still not fit. So you need three numbers: weight, width and where the weight is carried.

Use respectful language. Many teams say "person of size" or "patient of size." Do not use "bariatric" as a label for a person in a hallway conversation.

Everything Has a Limit

Standard equipment often has a maximum capacity of 250 or 300 pounds, the VA notes, and some older buildings may be full of it. Check everything the person will touch, including things you never think about.

Pay attention to toilets. Most ceramic toilets are rated at about 300 pounds. A 300-pound person who drops onto one can apply more force than their weight, so a toilet at that rating may not be safe for them. A bariatric commode over the toilet is a safer option.

Fit counts as much as the rating. A wheelchair should closely match the person's width without pressing on the hips, but it should not be too wide either. "Bariatric" on a label does not mean it fits this person. Many facilities mark expanded capacity equipment with a sticker showing its rating. If you cannot find a rating, do not use the item until someone confirms it.

Worked example. Mrs. Hayes weighs 412 pounds. She needs to go from her bed to a chair.

• Bed: rated 750 pounds. Pass.
• Lift: rated 600 pounds. Pass.
• Sling: rated 500 pounds and fits her hip measurement on the chart. Pass.
• Bedside chair: standard, rated 300 pounds. Fail.

The whole plan stops at the chair. Before you move her, get a rated chair of the right width, and check it fits in the room with the lift and the team.

How Weight Is Carried

Body shape changes the plan.

• Weight carried high (apple shape): legs may be close to normal, but walking can be hard and breathing can suffer. Watch for skin damage between the abdomen and the thighs.
• Weight carried low (pear shape): the person often cannot reach the groin to clean themselves, so moisture and skin damage are common there. Wide hips can change the chair they need.
• Large abdominal fold: a large fold of the abdomen is called a pannus or panniculus. It can hang down to the thighs or lower, and it can get in the way of walking, sitting and using a sling. It shifts the person's center of gravity, so it can raise their risk of falling. An abdominal binder or a pannus sling may be used, but only as the nurse directs.

Plan the Move as a Team

A team move fails when four people each do something different.

1. Pick a leader. One person calls the steps. Everyone else follows that voice.
2. Count your people. The number depends on the task and on the person's weight and ability to help. More hands are needed to place a sling or to roll a person.
3. Get the equipment first. Check that it is charged and working, and clear the room. Handling should happen at waist height, with no reaching.
4. Ask the person. They have been living in this body for years. Ask, "What works best when you turn?" They may also be able to help a lot.
5. Talk through the plan. Everyone should know their job, the signal and what happens if the person feels unwell.
6. Move on the count.
7. Check the person afterward.

Use friction-reducing devices, such as slide sheets, to slip a sling under the person and to take it out. This cuts the force on your body and protects the person's skin.

Limbs Are Heavy

VA guidance says that a limb generally makes up about 15 percent of total body weight. That means the leg of a 300-pound person weighs at least 45 pounds, which is more than the 35-pound safe patient handling benchmark.

Worked example. Mrs. Hayes weighs 412 pounds. 412 x 0.15 = about 62 pounds for one leg. You need to wash her leg and check her heel. Holding it up with your hands means you are supporting 62 pounds in an awkward position. Use a limb sling on the lift, a leg lifter, or a second person with a positioning aid, as your equipment allows. Do not let a coworker hold a leg while you work.

Rolling and Repositioning

Use a lift with a repositioning sling if you have one. Otherwise, use friction-reducing sheets and enough people. Never pull on the person's arms or legs, and do not pull on a skin fold.

If the person can help, ask them to bend their knees and push. Let them use the side rails if the plan allows it. Use the bed's power features to help with the move.

Warning: A person of size who rolls or slips can pin you against a wall or a bed frame, especially in a small room. Keep your feet clear and keep a way out.

Breathing Comes First

Extra weight on the chest and abdomen makes breathing harder. Lying flat lets the abdomen press up against the diaphragm, the muscle that drives breathing. VA guidance says to raise the head of the bed to about 45 degrees to help breathing, and to avoid long periods lying flat. Follow the care plan, which may give another angle.

Before you lay anyone flat for a sling or a bath, ask the nurse if it is safe, and keep it as short as you can.

Stop and call the nurse if the person:

• Has new or worse shortness of breath.
• Looks pale or blue around the lips or fingernails.
• Becomes restless or less alert.
• Says that they cannot breathe lying down.

Do not rush the person. Many people need rest breaks during a move, because they become short of breath quickly. Also tell the nurse if the person prefers to sleep in a recliner. It can seem like a good fix, but it can lead to skin damage and it makes an emergency response harder. The team needs to know so that they can plan another option.

Skin in Folds and Unexpected Places

Skin folds are dark, warm and moist. This makes them a good place for bacteria and yeast to grow. Skin rubbing on skin can cause a rash called intertrigo, and it can break down.

Look at these places during care, and lift each fold gently.

• Under the breasts.
• Under the pannus.
• In the groin and between the thighs.
• In folds at the back, arms and neck.
• Hips and thighs, where a chair or bed may be too tight.
• Under tubes and catheters, which can sink into a fold.
• Where a CPAP mask touches the face.
• Along the sides of the feet.

Clean each fold gently, as the plan says, and pat dry. Do not rub. Use only the products that are ordered, and keep them out of open areas. If the plan uses a fabric or a dressing in a fold, follow it exactly.

Report the following the same day: redness, a smell, moisture that does not clear, a rash, broken skin or any new sore. A pressure injury can hide in a fold. It can also form on the hip from a chair that is too narrow, even when the tailbone looks fine.

Keep to the turning plan too. People of size are at high risk of pressure injuries, and fat tissue is especially easy to damage because it has a poor blood supply.

Falls and Getting Up

Do not try to catch a person who is falling. Move anything nearby that could hurt them, try to keep their head from hitting something and call for help.

After a fall, stay with the person and get the nurse. Nobody moves them until a nurse or emergency crew has checked them. A person of size should never be lifted from the floor by hand. Your facility may have a lift rated for the floor or an air-assisted lifting device, which uses layers of air mattress to raise the person. Some of these can support up to 1,200 pounds. Know where yours is kept, and how to get it.

Floor-based lifts are harder to use in tight spaces. Do not use one with a person who is agitated or combative, because it can tip.

In a home, do not try to get the person up alone. Call your agency. If you cannot get them up safely, call 911. Keep them warm and stay with them until help comes. The care plan should already include a plan for this, so ask about it on your first visit.

Dignity Is Part of Safety

Many people of size have been humiliated in health care. Some avoid going in for care because of it. VA guidance names emotional harm from bias as one of the greatest sources of harm for these patients. That harm also affects safety, because a person who feels judged may not tell you about pain, a sore or a near-fall.

• Weigh the person in private. Do not announce or discuss the number.
• Do not talk about equipment limits within earshot, as if they were a problem the person caused.
• Bring the right gown, cuff and chair before you start, so that the person is not left waiting.
• Do not joke about weight, sigh, or call for "extra people" in a loud voice.
• Keep the person covered during a team move.
• Treat them as the expert on their own body.

If you hear coworkers making jokes, speak up or tell your supervisor.

Common Mistakes

Check Your Understanding

1. A new resident weighs 290 pounds and has very wide hips. Someone says she is under 300 pounds, so the standard wheelchair is fine. What do you say?

Weight is not the only check. If her hips do not fit, the chair can cause pressure injuries, and she may not be safe in it. Ask the nurse to get a chair that fits both her weight and her width.

2. You need to clean under a man's 320-pound frame, and a coworker offers to hold his leg up. How much does the leg weigh, and what should you do instead?

320 x 0.15 = about 48 pounds, which is more than the 35-pound benchmark. Use a limb sling or leg lifter, or another positioning aid.

3. During a sling placement, the patient lies flat and becomes short of breath and restless. What do you do?

Stop, raise the head of the bed and call the nurse right away.

4. You lift a resident's abdominal fold and see a red, wet, bad-smelling rash. What do you do?

Clean and pat it dry as the plan says, and report it to the nurse the same day. Do not add a cream or powder that has not been ordered.

5. A client in her home slips to the floor. She is awake and says nothing hurts, but you cannot get her up. What do you do?

Stay with her, keep her warm and call your agency. Do not lift her by hand. Call 911 if you cannot get her up safely or if she has any sign of injury.

Key Takeaways

• Bariatric means the person's weight or size affects safe care, not just a number on a scale.
• Check weight, width and height for everything the person will touch.
• Pick a leader, get enough people and ask the person what works for them.
• A leg is about 15 percent of body weight, so use equipment to hold it.
• Protect breathing, and avoid laying the person flat without checking.
• Check skin folds and other hidden spots, and report changes the same day.
• Respect is part of safe care.