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, NEBC; Kristine Ehlers RN, BSN, CCRN
Procedure: Prevalon® Turn and Position 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 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 Turn and Position System Indications for Use:
1.
2.
3.
4.
5.
6.
7.
Patient requires assistance in turning q2 hrs or more frequently and/or has a Braden friction sub-score of
< 1. 1
Incontinence of urine or stool and/or a Braden moisture sub-score of < 2. 1
Has a mobility sub-score of < 2 in combination with an abnormal friction or moisture sub-scale. 1
Progressive Mobility protocol in use.
BMI >30, weight up to 550 lbs., unequally distributed adipose tissue making positioning difficult.
High risk patients; Likely to be ventilated >24 hrs, history of a previous pressure ulcer, evidence of
significant third spacing, or low albumin.
Intractable pain with movement.
Prevalon Turn and Position System Sizing:
Prevalon Standard:
1. For use with a 36” wide bed (accommodating patients up to 550 lbs.)
Cautions:
1.
2.
3.
4.
5.
DO NOT use Prevalon® Turn and Position System to lift patients.
Patient repositioning should always be performed following your facility’s safe patient handling policies
and procedures.
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.
Periodically check product for signs of wear. Replace if product is damaged.
Weight capacity: 550 lbs.
Contraindications:
1.
2.
Unstable spine
(add other contraindications as necessary)
Discontinue use:
1.
2.
3.
When able to independently perform a turn and assist with mobility has a Friction sub-score of 2 or
greater.
No longer at risk for potential moisture injury and or a Braden sub-score of 3 or greater
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. http://www.ihi.org/IHI/Programs/Campaign/PressureUlcers.htm.
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
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 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.
Rationale
To provide correct
positioning of the
caregiver to ensure
ergodynamic
movement techniques
to reduce the potential
of caregiver injury.
Special Considerations
If on a low air loss bed,
maximum inflation is
recommended to enhance
ease of use.
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.
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.
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.
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.
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.
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.
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.
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.
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
© ADVANCING NURSING LLC, 2014
22274
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.