Positioning a Patient in Bed for CNAs: Step-by-Step Guide and Exam Tips

Positioning a patient in bed means placing a resident in a specific body position and supporting that position with pillows so the resident is comfortable, safe, and protected from injury. In a nursing facility, residents who cannot reposition themselves are turned and repositioned by the care staff, typically every two hours, to prevent pressure injuries.

A pressure injury (also called a pressure ulcer or bed sore) is damage to the skin and tissue that occurs when a bony area of the body is compressed against a surface for a prolonged period. When you press a bony prominence like a hip or a heel against a mattress without moving, blood flow to that area decreases. Without blood flow, tissue begins to break down. A small area of redness that appears after an hour or two of pressure can develop into a deep wound that takes months to heal. For elderly residents with fragile skin and limited circulation, pressure injuries are a serious and sometimes life-threatening complication. Turning and repositioning on schedule is one of the most direct ways a CNA prevents them.

Why This Skill Matters on the CNA Exam

Important: The official NNAAP skill is called "Positions On Side," meaning the exam tests specifically the lateral (side-lying) position. You will not be asked to demonstrate Fowler's, supine, or Sims' on the skills exam. This page covers all four positions because you will use them daily in clinical practice, but the lateral position section below is what you need to master for exam day.

The evaluator uses a standardized checklist and watches for specific behaviors related to resident safety and comfort. The most closely observed elements are pillow placement to protect bony prominences, correct alignment of the body in the lateral position, and verification that the resident is not resting on an unprotected bony area. The evaluator also watches for correct infection control steps, proper bed height management, and call light placement at the end of the procedure.

Students who struggle with this skill usually forget one or more pillow placement steps. Learning the positions and their required supports in this lesson will give you a clear framework to follow under exam pressure.

What You Need

2 to 4 positioning pillows (standard bed pillows work for most positions)
Draw sheet or turning sheet if available (a flat sheet folded under the resident used for repositioning)
Bed with adjustable head elevation

Positions Used in CNA Practice

Supine (Flat on the Back)

The resident lies on their back with the head aligned with the spine. The arms rest at the sides or on pillows. A pillow is placed under the lower legs so the heels are elevated off the mattress surface. Heels are one of the highest-risk areas for pressure injury because they are bony and have very little tissue padding. Floating the heels by elevating the lower legs prevents prolonged contact with the mattress. This position is used for sleep, rest, and various care procedures.

Fowler's Position (Sitting Up in Bed)

Fowler's position is a supine position with the head of the bed elevated. Standard Fowler's is 45 to 60 degrees. Semi-Fowler's is 30 to 45 degrees. High Fowler's is 60 to 90 degrees. This position is used for eating (head raised to prevent aspiration), for residents with breathing difficulty (upright position helps expand the lungs), and for residents who need to be partially upright for extended periods. When a resident is in Fowler's position, the sacrum (the triangular bone at the base of the spine) is at elevated pressure risk because the seated angle pushes it into the mattress. A small pillow or support under the knees can reduce pressure on the sacrum and also prevent the resident from sliding down in bed.

Lateral (Side-Lying)

The resident lies on their side. This is the position you will most often place residents in for repositioning to relieve pressure from the back and sacrum. The NNAAP exam focuses on this position more than any other because it requires the most steps and the most supporting pillows to do correctly. Proper lateral positioning with pillow support is described in detail in the step-by-step section below.

Sims' Position (Semi-Prone)

In Sims' position, the resident lies at approximately a 45-degree angle between lateral and prone (face down). The lower arm is positioned behind the resident, the upper knee is bent forward and supported with a pillow, and the upper arm is bent and resting in front. This position is used for enemas, rectal procedures, and rectal temperature measurement. It allows access to the rectal area while keeping the resident at a partial side-lying angle. Sims' is less commonly seen on the exam than lateral, but knowing it is a requirement of CNA training.

Bony Prominences to Protect

These are the areas of the body where bone is close to the skin surface, leaving very little tissue to cushion against a hard surface. Every positioning procedure requires that these areas either not be pressed against the mattress or that they be padded if contact is unavoidable.

Heels
Ankles (the bony bumps on either side)
Sacrum and coccyx (the base of the spine, especially at risk in Fowler's)
Hips (greater trochanters, the bony points you feel on the outer hip)
Shoulder blades
Elbows
Ears (can fold under the head during lateral positioning)
Back of the head (occipital area)
Knees (inner surfaces press together in lateral position)

Step-by-Step: Lateral (Side-Lying) Repositioning

This is the most commonly tested position. The steps below move a resident from supine to lateral.

Wash your hands. Perform hand hygiene before touching the resident or the bed.
Gather pillows. Have at least three pillows ready before you begin moving the resident: one for behind the back, one for between the legs, and one for the upper arm.
Identify the resident and explain the procedure. Check the name band, greet the resident by name, and tell them you are going to reposition them onto their side.
Provide privacy. Close the curtain or door.
Raise the bed to working height. Raise the bed so you can work comfortably without bending at the waist. This protects your back and gives you better control during the repositioning movement.
Lower the side rail on the side the resident is currently on. You will reposition from this side. The far side rail should remain up for safety.
Move the resident to the center or far side of the bed. Before rolling, shift the resident slightly toward the far side of the bed so they will end up centered when rolled toward you. If you roll them without first moving them away from you, they may end up at the edge of the bed when the roll is complete.
Cross the far arm over the chest. Ask the resident to fold their arm across their chest if able, or do it for them. This keeps the arm from getting trapped under the body during the roll.
Cross the far leg over the near leg. Lift the far ankle and place it over the near ankle. This sets up the body to follow the leg during the roll and reduces the effort needed to complete the turn.
Stand on the side the resident will face when rolled. You will be rolling the resident toward you, which gives you maximum control over the movement.
Place your hands at the shoulder and the hip. One hand at the far shoulder, one hand at the far hip. If a draw sheet is in place, grasp it at these points instead and use it to roll the resident.
Roll the resident toward you in a single controlled movement. Keep the body aligned as it rolls. Do not let the head lag behind or the hips twist ahead of the shoulders. Move the whole body as a unit.
Place a pillow behind the back. Tuck a pillow firmly behind the resident's back from the shoulders down to the buttocks. This prevents the resident from rolling backward. Without this support, the position is unstable and the resident may roll back to supine.
Place a pillow between the knees. This is a critical step. In lateral position, the upper knee presses against the lower knee, with the full weight of the upper leg creating pressure on that bony contact point. A pillow between the knees extends down between the lower legs to cushion this contact and also keeps the hips in neutral alignment. Lateral positioning without this pillow is incomplete.
Support the upper arm. Place a pillow under the upper arm so it rests comfortably and is not dangling forward or pressing against the resident's chest.
Check the head and ear. Confirm the resident's head is on the pillow and the ear is not folded under the head. A folded ear under the head creates pressure on the ear cartilage and is a commonly missed inspection step.
Verify body alignment. The spine should be straight. The head and neck should be aligned with the spine. No bony prominences should be pressing directly against an unprotected surface.
Raise the side rail and lower the bed. Raise the side rail on your side before lowering the bed to its safe position.
Place the call light within reach. Ensure the resident can reach the call light from their new position before you leave.
Wash your hands. Perform hand hygiene before leaving the room.
Record and report. Document the position and time. Report any skin redness, bruising, or breakdown you observed during the repositioning to the nurse.

What the Examiner Looks For

Bed raised to a safe working height before the procedure begins
Far side rail remains up while near rail is lowered
Resident's arm and leg are crossed before rolling
Resident is rolled as a unit with body alignment maintained
Pillow placed behind the back for support
Pillow placed between the knees and lower legs
Upper arm supported with a pillow
Ear is checked and not folded under the head
Resident's head is on the pillow and spine is aligned
Side rail raised and bed lowered at the end
Call light placed within the resident's reach
Hand hygiene performed before and after the skill

Common Mistakes to Avoid

Forgetting the pillow between the knees. This is the most commonly missed step in lateral positioning. It is on the NNAAP checklist. Make it a habit to place this pillow every single time.
Not placing a pillow behind the back. Without back support, the lateral position is unstable. The resident may gradually roll back to supine, defeating the purpose of the repositioning.
Not crossing the arm and leg before rolling. Rolling without crossing these limbs is harder to execute and may result in the arm being trapped under the body.
Forgetting to check the ear. The ear is small and easy to overlook. A folded ear causes discomfort and can develop a pressure sore quickly because the cartilage has limited blood supply.
Rolling the resident away from you instead of toward you. Rolling away from you means pushing the resident rather than pulling, which gives you less control over the movement and the direction of the roll.
Not repositioning the resident to the far side of the bed first. Skipping this step often results in the resident ending up too close to the edge of the bed after the roll. Always move the resident toward the far side before rolling so they land centered.

Printable Practice Checklist

Use this checklist when practicing with a lab partner. Check off each step as you complete it.

Washed hands
Gathered at least 3 positioning pillows
Identified resident
Explained procedure
Provided privacy
Raised bed to working height
Lowered near side rail (far rail remains up)
Moved resident toward far side of bed
Crossed far arm over chest
Crossed far leg over near leg
Positioned self on the side resident will face
Placed hands at shoulder and hip (or on draw sheet)
Rolled resident toward self as a unit
Placed pillow behind back for support
Placed pillow between knees and lower legs
Placed pillow under upper arm
Checked that ear is not folded
Verified head is on pillow and spine is aligned
Raised side rail
Lowered bed to safe height
Placed call light within resident's reach
Washed hands
Recorded position and time
Reported any skin findings to nurse

Positioning a resident correctly takes practice with pillow placement and body alignment. Find CNA programs with clinical skills training to practice these techniques before your exam.

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