Bariatric M2 – Mobility & Moisture Protocol
Authors: Kathleen M Vollman MSN, RN, CCNS, FCCM, FAAN, Clinical Nurse Specialist, Educator,
Consultant, ADVANCING NURSING LLC; Wanda Pritss 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
Procedure: Prevalon® XL/XXL Turn and Position System with Microclimate
Body Pad
Purpose:
The purpose of the Prevalon XL/XXL Turn and Position System with Microclimate Body Pad 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 facilitate easy repositioning while diminishing 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 XL/XXL Turn and Position System Indication for Use:
1. Patient requires assistance in turning q2 hrs or more frequently and/or has a Braden mobility
score of 1.
2. Incontinence of urine or stool and or a Braden moisture score of 2 or less.
3. BMI >30, weight >350 lbs., up to 550 lbs., unequally distributed adipose tissue making
positioning difficult.
4. Patient unable to assist with movement in bed
5. Progressive Mobility protocol in use.
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 XL/XXL Turn and Position System Sizing:
Prevalon XL:
1. For use with a 40-52” wide bed (accommodating patients up to 550 lbs.)
Prevalon XXL
2. For use with a 45” wide bed or greater (accommodating patients up to 550 lbs.)
Additional Evidence Based Prevention Strategies To Consider When Using the Prevalon
XL/XXL Turn & Position System:
Risk assessment of the patient’s skin using skin a reliable and valid tool (Braden). Acting on low
scores in the subscale of the risk tool may provide a more targeted use of prevention resources.
2. Positioning to reduce pressure and shear injuries
1.
a. Repositioning should be undertaken to reduce the duration and magnitude of pressure
over vulnerable areas of the body. Establish a positioning schedule at a minimum of
every two hours or more frequently based on the individuals condition and the support
surface in use
b. Repositioning, using the 30° semi fowlers or the prone position or the 30° tilted side
lying positions if the individual can tolerate these positions, and the medical condition
allows.
c. If sitting in bed is necessary, avoid greater than 30° head of the bed elevation and/or a
slouch position that places pressure and shear on the sacrum and coccyx for greater
than 60 minutes. Positioning with pillows under the arms may help slouching.
d. Limit the time a patient spends seated in a chair without pressure relief. (<2 hours)
e. Use an active support surface, whether it is an overlay or mattress, for patients at higher
risk of pressure ulcer development, where frequent manual turning is not possible.
f. Greater than three layers of linen reduce the effectiveness of the pressure reduction
support surface.
g. For patients who are not alert & cooperative use a heel protecting device. The device
should elevate the heel completely off the bed and distribute the weight of the leg along
the calf without putting additional pressure on the Achilles tendon. For completely
immobilized patients consider a device that incorporates prevention of external rotation
of the legs to prevent plantar flexion contractures.
h. Document the repositioning schedule including the frequency position and evaluation
the outcome and use of heel protection aids.
i. When turning acute and critically ill patients, the evidence supports waiting 5-10
minutes before assessing toleration to position change.
3. Moisture management
a. Cleansing of the skin as soon as soiling occurs
b. Use of a barrier on the skin with every soiling episode. Dimethicone, when in
combination with zinc or petroleum, serves as an effective barrier against both urine
and stool. A one step system of a barrier cloth is recommended by the IHI to improve
compliance regarding skin protection related to urine and stool.
c. Use of an (absorbent) incontinent pad/body pad to wick moisture away from the skin;
however, still allow for airflow/breathing.
d. Excessive linen use impacts the breathability of devices and or surfaces design to help
maintain a healthy microclimate.
Cautions:
1. DO NOT use Prevalon XL/XXL 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. If under 350 lbs., use Prevalon Standard Size Turn & Position System
Contraindications:
1. Unstable spine
2. (add other contraindications as necessary)
Discontinue use:
1.
2.
3.
4.
When able to independently perform a turn and assist with mobility.
No longer at risk for potential moisture injury.
Braden mobility score of 3.
Braden moisture score of 3.
References:
1. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention
2.
3.
4.
5.
6.
7.
8.
9.
10.
and treatment of pressure ulcers: clinical practice guideline. Washington D.C. National Pressure
Ulcer Advisory Panel;2009.
Institute for health care improvement: Prevent pressure ulcers.
http://www.ihi.org/IHI/Programs/Campaign/PressureUlcers.htm. Accessed October
7th, 2007
Courtney BA, Ruppman JB, Cooper HM. Save our skin: Initiative cuts pressure ulcer incidence in
half. Nursing Management. 2006;37(4):35-46.
Driver DS. Perineal dermatitis in critical care patients. Critical Care Nurse 2007;27(4):42-46.
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.
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):261269
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.
Gray M, Weir D. Prevention and treatment of moisture-associated skin damage (maceration) in
the periwound skin. J WOCN. 2007;34(2):153–157.
Vollman KM. Ventilator-associated pneumonia and pressure ulcer prevention as targets for
quality improvement in the ICU. Critical Care Nursing Clinics of North America, 2006;18:453-467
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® XL/XXL Turn and Position System with Microclimate
Body Pads


Wash hands
Ensure privacy for the patient
Steps
Rationale
Special Considerations
Instructions for Use
with Empty Bed:
To Begin: Make sure bed
brakes are locked, bed is
flat (if patient condition
To provide correct
positioning of the
caregiver to ensure
If on a low air loss bed,
maximum inflation is
recommended to enhance
allows) and at waist level.
1. The Mattress cover
provided with the
Prevalon system takes the
place of fitted/flat sheet.
Unroll on mattress. Set
Glide Sheet and
Microclimate Body Pad
aside until patient is
available.
Place the two black elastic
corner straps around
underside of mattress at
head of bed. Mattress
cover remains in place for
length of patient stay.
2. Secure Straps on
Mattress Cover: Attach all
4 black corner straps
loosely first. Disconnect
the short end of black side
straps and loop around
restraint target or other
points of attachment.
Fasten straps loosely to
part of frame that moves
during bed adjustment.
Then tighten all straps
securely and make sure
Mattress Cover
is completely taut on
mattress.
ergodynamic
movement techniques
to reduce the potential
of caregiver injury.
ease of use.
A mattress cover comes with
the Prevalon system. The
mattress cover stays in place
through corner straps and
helps facilitate the
interaction between the
mattress cover and glide
sheet for easier movement
of the bariatric patient.
3. After Patient is
Transferred to Bariatric
Bed: Align upper edge of
Glide Sheet with patient’s
shoulders. Roll patient
away from you onto
his/her side. Tuck Glide
Sheet with Body Pad
under patient and unroll
toward you. Raise bed rail.
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.
They are not necessary with
the device in use.
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
4. Go to opposite side of
bed and lower bed rail.
Roll patient away from
you onto his/her side.
Unroll Glide Sheet with
Body Pad toward you.
Return patient to supine
position. Center Glide
Sheet with Body Pad
under patient following
safe patient handling
policy/procedure.
5. Centering Patient on
Bed: Gently slide patient
using black handles on
Glide Sheet to align hips
hinge point on bed.
Prevent patient’s heels
and head from dragging
across bed during
repositioning.
6. Attach Anti-Shear Strap
on Glide Sheet to the
Mattress Cover.
following the same
procedure as placement.
7. Insert Body Wedges
blue side up/gray side
down between Mattress
Cover and Glide Sheet by
sliding over fabric flap on
Mattress Cover. Fabric flap
should be folded down
over white hook and loop
fastener when inserting
Wedges.
Off loading of the
sacrum is essential to
reduce the risk of
pressure ulcers in
patients who are
unable to support
themselves in a side
lying position
8. Position the first Wedge
under patient’s back.
Position second Wedge
under patient’s thigh and
buttocks. Leave
approximately the width
of your hand (~4”/10 cm)
between the positioned
Body Wedges at the
sacrum.
9. Grasp black handles on
Glide Sheet and gently
PULL (don’t lift) patient
across bed horizontally
toward you until patient is
angled between 20-30° on
Body Wedges.
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.
10. As patient is
positioned, fabric flap will
fold back and Wedges will
lock into place on hook
and loop fastener.
Underside of Glide Sheet
can also be adhered to
hook and loop fastener on
outside of Wedges. When
positioned correctly,
sacrum should be
offloaded (free from
contact). Prevent patient’s
heels and head from
dragging across bed
during repositioning.
Smooth out any wrinkles
in Glide Sheet and Body
Pad. Raise bed rails.
11. Adjust head of bed to
desired angle.
12. Repositioning Patient:
To reposition patient,
gently pull up on Body
Wedges to release from
hook and loop fastener.
Remove Wedges and
follow steps 8-11 on
opposite side of patient.
Refer to your facility’s
protocol for frequency of
repositioning.
Off loading of the
sacrum is essential to
reduce the risk of
pressure ulcers in
patients who are
unable to support
themselves in a side
lying position
Without attachment of the
Anti-Shear Strap, the shear
reduction technology of the
device is reduced.
Instructions for Placing
Device with Patient in
Bed:
1. Align upper edge of
Mattress Cover with head
of bed.
2. Unfold Glide Sheet and
Microclimate Body Pad.
Align with patient’s
shoulders. Roll patient
away from you onto
his/her side. Tuck
Mattress Cover, Glide
Sheet with Body Pad
under patient and unroll
toward you. Raise bed rail.
On opposite side of bed,
roll patient away from you
onto his/her side. Unroll
Mattress Cover, Glide
Sheet and Body pad
toward you.
3. Secure Mattress Cover
as outlined in step 2 under
“Instructions for Use with
Empty Bed.” Then refer to
steps 5-11 under “After
Patient is Transferred to
Bed.” For instructions on
repositioning patient,
refer to step 12.
Other Instructions:
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.
They are not necessary with
the device in use.
Changing Microclimate
Body Pad: Dispose of
Body Pad when soiled
or saturated. Replace
only with Prevalon®
Microclimate Body Pads
(Reorder # 7255 for XL;
7260 for XXL). 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, 2011
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