M2– Mobility/Friction & Moisture Protocol

Authors: Kathleen M Vollman MSN, RN, CCNS, FCCM, FAAN, Clinical Nurse Specialist, Educator, Consultant, ADVANCING NURSING LLC; Wanda Pritts RN, MSN, APN-CNS, CCRN, PCCN, CEN, Clinical Nurse Specialist – Critical Care; Renee Malandrino APN, CWOCN; Diane Zeek MS, APN, NP-C, CWOCN; Frank Schneider RN, MSN, CCRN, NE-BC; Kristine Ehlers RN, BSN, CCRN

Procedure: Prevalon®Turn andPosition System 2.0

Purpose:

The purpose of the Turn and Position System 2.0 is to help the caregiver achieve the goal of:

  • Offloading pressure (turning)q2 hrs or more frequently to reduce the risk of pressure ulcers
  • Maintaining a lateral position
  • Controlling the microclimate to eliminate the risk of moisture related skin injury.

The system is designed to facilitateeasy repositioning whilediminishing shear forces and minimizing the physical effort required for turning or repositioning by caregivers, thus reducing the risk of injury to the patient and caregiver.

Prevalon Turn and Position System Indications for Use:

1.Patient requires assistance in turningq2 hrs or more frequently and/or hasa Bradenfriction sub-score of 1.1

2.Incontinence of urine or stool and/or a Braden moisturesub-score of 2. 1

3.Has a mobility sub-score of < 2 in combination with an abnormal friction or moisture sub-scale. 1

4.Progressive Mobility protocol in use.

5.BMI30, weight up to 550lbs., unequally distributed adipose tissue making positioning difficult.

6.High risk patients; Likely to be ventilated >24 hrs, history of a previous pressure ulcer, evidence of significant third spacing, or low albumin.

7.Intractable pain with movement.

Prevalon Turn and Position System Sizing:

Prevalon Standard:

1.For use with a36” wide bed (accommodating patients up to 550 lbs.)

Cautions:

1.DO NOT use Prevalon® Turn and Position System to lift patients.

2.Patient repositioning should always be performed following your facility’s safe patient handling policies
and procedures.

3.For single patient use only. If soiled, wipe the Glide Sheet or Body Wedges with damp cloth to clean. Do not launder. Laundering impacts the effectiveness of the shear protection.

4.Periodically check product for signs of wear. Replace if product is damaged.

5.Weight capacity: 550 lbs.

Contraindications:

1.Unstable spine

2.(add other contraindications as necessary)

Discontinue use:

  1. When able to independently perform a turn and assist with mobility has a Friction sub-score of 2 or greater.
  2. No longer at risk for potential moisture injury and or a Braden sub-score of 3 or greater
  3. Braden mobility sub-score of 3 with friction and/or moisture risk no longer present.

References:

  1. Tescher AN,Branda ME, Byrne TJ, Naessens JM.All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks.. J WOCN. 2012;39(3):282-291.
  2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington D.C. National Pressure Ulcer Advisory Panel;2009.
  3. Institute for health care improvement: Prevent pressure ulcers. Accessed October
    7th, 2007
  4. Gould D, James T, Tarpey A, et al. Intervention studies to reduce the prevalence and incidence of pressure sores: a literature review. J Clin Nurs, 2000;9(2):163-177.
  5. Bergstrom N, Braden B, Kemp M, Champagne M, Rudy E. Predicting pressure ulcer risk: A multisite study of the predictive validity of the Braden scale. Nursing Research,1998;47(5):261-269
  6. Black J, Baharestani M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel’s Updated Pressure Ulcer Staging System. Derm Nurs. 2007;19(4):343–350.
  7. Gray M, Weir D. Prevention and treatment of moisture-associated skin damage (maceration) in the periwound skin. J WOCN. 2007;34(2):153–157.
  8. Warner D, Konnerth K, (1993). “A patient teaching protocol for pressure ulcers prevention and management” Ostomy and Wound Management, 39 (2):
    35-43

Procedure: Prevalon® Turn and Position System 2.0

  • Wash hands
  • Ensure privacy for the patient

Steps / Rationale / Special Considerations
Prior to Patient Positioning:Make sure bed brakes are locked, bed is flat (if patient condition allows) and at waist level. Always follow your facility’s safe patient handling policies and procedures. / / To provide correct positioning of the caregiver to ensure ergodynamic movement techniques to reduce the potential of caregiver injury. / If on a low air loss bed, maximum inflation is recommended to enhance ease of use.
To Begin
1.Lower bed rail closest to you. Unfold Glide Sheet with Body Pad alongside of supine patient. Tag on underside of Glide Sheet should be unfolded toward head of bed. Align upper edge of Glide Sheet with patient’s shoulders. / / The implementation team may decide to place this on all beds within a unit so the device is ready to be used.
Centering Device Under Patient
2.Roll patient away from you onto their side. Tuck Glide Sheet with Body Pad under patient and unroll toward you. Raise bed rail. /
3.Go to opposite side of bed and lower bed rail. Roll patient away from you onto their side. Unroll Glide Sheet with Body Pad toward you. Return patient to supine position. / / Use of a wide base of support is extremely important to improve balance and prevent self-injury during the turning procedure. / Remove any blanket, draw sheet, diaper or incontinence pad previously in use to manage lifting/repositioning and containment of moisture to protect the linens. They are not necessary with the device in use.
Patient Alignment
4.Gently slide patient using black handles on Glide Sheet to align hips with hip placement indicator or hinge point on bed. Prevent patient’s heels and head from dragging across bed during repositioning. /
Upper Wedge Placement
5.Place Wedge with label side up. Lift edge of Glide Sheet and gently push wedge under patient, allowing Wedge to initiate patient turning movement. / / The anti-shear slide and glide technique is supported by the technology so boosting/lifting is not required to reposition in the bed. / While the device is underneath the patient natural movement towards the head of the bed will occur with multiple slide and guide repositions. Once the device is no longer covering the length of the torso it needs to be re-aligned following the same procedure as placement.
Lower Wedge Placement
6. Place Anchor Wedge with label side up. Grasp Anchor and slide under patient’s thighs. Wedges should be placed approximately 8 in./20 cm apart at the sacrum. Gently push Wedge under patient as before, allowing Wedge to initiate patient turning movement. / / Off loading of the sacrum is essential to reduce the risk of pressure ulcers inpatients who are unable to support themselves in a side lying position.
7.Go to opposite side of bed and pull Anchor under patient’s thighs toward you until it is taut, without pulling wedge. Raise bedrail and return to other side of bed. / / After placement of the Body Wedges, assess for off loading of the sacrum by placing your hand between the wedges to ensure the sacrum is free from contact with the mattress.
Complete the Microturn
8.With both hands, grasp black handles on Glide Sheet near patient’s hips. Gently PULL (don’t lift) until patient is positioned at desired angle. Once positioned, sacrum should be offloaded (free from contact). Prevent patient’s heels and head from dragging across bed during repositioning. Smooth out any wrinkles. Raise bed rails. /
Repositioning Patient
9.To reposition patient, remove Body Wedges by grabbing corner and rotating wedge out. Move to opposite side of patient and follow steps 4-8. Refer to your facility’s protocol for frequency of repositioning. /
Using Boost Straps
10.Boost Straps may be used to assist in repositioning. Always follow recommended posture and technique. Locate orange straps on Glide Sheet. Slide both hands through strap loops until they are wrapped around your wrists/ forearms. Grasp the straight part of each orange strap and reposition patient as desired. /
Changing Microclimate
Body Pad
Dispose of Body Pad when soiled or saturated. Replace only with Prevalon® Microclimate Body Pads (Reorder # 7250). Edge of Microclimate Body Pad must be aligned with edge of Glide Sheet / Cleaning Instructions: If Glide Sheet or Body Wedges become soiled, wipe with damp cloth to clean. Do not launder; laundering will compromise the function of this device. The only changeable component of the system is the Microclimate Body Pad.

© ADVANCING NURSING LLC, 2014

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