Address Risk Factors for Sacral Pressure Ulcers1 and Healthcare Worker Injury

Prevalon™ AirTAP System™

PRESSURE

FRICTION

SACRAL PRESSURE ULCERS

SHEAR

MOISTURE

HIGH FREQUENCY TASK

POSTURE HEALTHCARE EXERTION WORKER

See it in action! Scan with your phone or visit http://sageproducts.com/videos/airtap/training/

INJURY

HIGH RISK TASK Reference: 1. Clinical Practice Guidelines: the use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. Royal College of Nursing, Oct 2003

To reorder, contact Sage Customer Service 800-323-2220 / www.sageproducts.com 24624 © 2016 Sage Products LLC

Guidelines and Recommendations American Nurses Association1 Safe Patient Handling and Mobility (SPHM) Interprofessional National Standards Across the Continuum of Care

2.1.7 Reduce the physical requirements of highrisk tasks. The organization will focus on reducing the physical requirements of high-risk healthcare recipient transfer, repositioning, and mobilization, and other applicable tasks through engineering, safe work practice, and/or administrative controls. 4.1.5 Provide and strategically place SPHM technology for accessibility. The organization will develop a process for providing SPHM technology that ensures ease in accessibility. The quantity and type of SPHM technology will be sufficient to minimize risk for the healthcare recipient population served and the environment of care.

2010 Guidelines for Design and Construction of Health Care Facilities2

Occupational Safety and Health Administration (OSHA)3

Caregiver tasks that cause concern around safe patient handling

The majority of injuries and MSDs can be attributed to overexertion related to repeated transfer, repositioning, and ambulation of healthcare recipients.

Positioning | Repositioning • Returning a patient who has slid down in bed to the head of the bed is also a frequent manual move performed by caregivers. • These moves typically are among the highest-risk tasks performed by caregivers. • To reposition patients for their comfort and safety. Types of high-risk patient handling and movement tasks to be performed and accommodated • Positioning/repositioning in bed (side to side, up to the head of the bed). Patient handling and movement (PHAM) equipment categories include: • Air-assisted devices for repositioning patients up and from side to side in bed.

The Joint Commission4 Universal SPHM standards are needed to protect healthcare workers from injuries and MSDs. Addressing healthcare worker safety through SPHM will also improve the safety of healthcare recipients (patients).

REFERENCES: 1. Safe Patient Handling and Mobility Interprofessional National Standards Across the Care Continuum. American Nurses Association. 2013. 2. The Facility Guidelines Institute, April 2010, Patient Handling and Movement Assessments: A White Paper, Prepared by the 2010 Health Guidelines Revision Committee Specialty Subcommittee on Patient Movement. 3. Occupational Safety and Health Administration (OSH). (2013). Healthcare Facilities: Safe Patient Handling. Retrieved from http://www.osha.gov/SLTC/ healthcarefacilities/safepatienthandling.html 4. The Joint Commission. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. Oakbrook Terrace, IL: The Joint Commission, Nov 2012. http://www.jointcommission.org/

Prevalon® Pressure-Relieving Heel Protector Goes on in seconds for a secure, comfortable fit

HEEL PROTECTION

For use with calf circumference of 10”-18” (25cm-46cm)

Heel Pressure Ulcer Staging Guide

(Inside out) Do not overtighten straps

Sequential compression device compatible. Make sure tubing is not kinked or compressed against patient’s skin.

1

Pull boot up around foot.

2

Make sure patient’s heel is floated.

Wrap stretch panels around boot.

3

Adjust straps. Do not overtighten.

To reorder, contact Sage Customer Service 800-323-2220 www.sageproducts.com 21233D © Sage Products Inc. 2011

#7300 reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Comfort Shield® Barrier Cream Cloths ONE STEP Cleans + Treats + Protects

Hypoallergenic Durable

INCONTINENCE CARE

Skin Care for Incontinent Persons

Incontinence-Associated Dermatitis Intervention Tool

1. Cleanse incontinence ASAP and apply barrier.

2. Document condition of skin at least once every shift in nurseʼs notes.

3. Notify primary care provider when skin injury occurs and collaborate on the plan of care.

4. Consider use of external catheter or fecal collector.

5. Consider short term use of urinary catheter only if necessary.

Simple Interventions. Extraordinary Outcomes.

To reorder, contact Sage Customer Service Ultra soft, rinse-free

Copyright © 2008 Joan Junkin. All rights reserved. Please send request for permissions to [email protected]. 1. Bliss DZ, Zehrer C, Savik K, et al. Incontinence-Associated Skin Damage in Nursing Home Residents: A Secondary Analysis of a Prospective, Multicenter Study. Ost/Wound Mgmt. 2006;52:46–55. 2. Institute for Healthcare Improvement. Prevent Pressure Ulcers: How-To Guide. May 2007. Available at: http://www.ihi.org/nr/rdonlyres/5ababb51-93b3-4d88-ae19be88b7d96858/0/pressureulcerhowtoguide.doc, accessed 10/21/07. 3. Gray M, Bliss DB, ErmerSeltun J, et al. Incontinence-associated Dermatitis: A Consensus. JWOCN. 2007;34:45-54.

800-323-2220 www.sageproducts.com

xxxx 21250C © Sage Products Inc. 2011

reorder #

DEFINITION

HIGH-RISK

MODERATE IAD

SEVERE IAD

FUNGAL APPEARING RASH

Skin exposed to stool and/or urine is dry, intact, and not blistered, but is pink or red with diffuse (not sharply defined), often irregular borders. In darker skin tones, it might be more difficult to visualize color changes (white or yellow color) and palpation may be more useful.

Affected skin is bright or angry red – in darker skin tones, it may appear white or yellow.

Affected skin is red with areas of denudement (partial thickness skin loss) and oozing/bleeding. In dark skinned patients, the skin tones may be white or yellow.

This may occur in addition to any level of IAD skin injury.

Palpation may reveal a warmer temperature compared to skin not exposed. People with adequate sensation and the ability to communicate may complain of burning, stinging, or other pain.

This is painful whether or not the person can communicate the pain.

Skin is not erythematous or warmer than nearby skin but may show scars or color changes from previous IAD episodes and/or healed pressure ulcer(s). Person not able to adequately care for self or communicate need and is incontinent of liquid stool at least 3 times in 24 hours.1

INTERVENTION

EARLY IAD

Skin usually appears shiny and moist with weeping or pinpoint areas of bleeding. Raised areas or small blisters may be noted. Small areas of skin loss (dime size) if any.

Skin layers may be stripped off as the oozing protein is sticky and adheres to any dry surface.

Usually spots are noted near edges of red areas (white or yellow areas in dark skinned patients) that may appear as pimples or just flat red (white or yellow) spots. Person may report itching which may be intense.

1. Use a disposable barrier cloth containing cleanser, moisturizer and protectant.2

< Include treatments from box to left plus:

< Include treatments from box to left plus:

2. If barrier cloths not available, use acidic cleanser (6.5 or lower), not soap (soap is too alkaline); cleanse gently (soak for a minute or two – no scrubbing); and apply a protectant (ie: dimethicone, liquid skin barrier or petrolatum).

5. Consider applying a zinc oxide-based product for weepy or bleeding areas 3 times a day and whenever stooling occurs.

10. Position the person semiprone BID to expose affected skin to air.

Ask primary care provider to order an anti-fungal powder or ointment. Avoid creams in the case of IAD because they add moisture to a moisture damaged area (main ingredient is water).

11. Consider treatments that reduce moisture: low air loss mattress/overlay, more frequent turning, astringents such as Domeboro soaks.

1. If using powder, lightly dust powder to affected areas. Seal with ointment or liquid skin barrier to prevent caking.

12. Consider the air flow type underpads (without plastic backing).

2. Continue the treatments based on the level of IAD.

3. If briefs or underpads are used, allow skin to be exposed to air. Use containment briefs only for sitting in chair or ambulating – not while in bed.

6. Apply the ointment to a non-adherent dressing (such as anorectal dressing for cleft, Telfa for flat areas, or ABD pad for larger areas) and gently place on injured skin to avoid rubbing. Do not use tape or other adhesive dressings.

4. Manage the cause of incontinence: a) Determine why the patient is incontinent. Check for urinary tract infection, b) Consider timed toileting or a bladder or bowel program, c) Refer to incontinence specialist if no success.3

7. If using zinc oxide paste, do not scrub the paste completely off with the next cleaning. Gently soak stool off top then apply new paste covered dressing to area. 8. If denuded areas remain to be healed after inflammation is reduced, consider BTC ointment (balsam of peru, trypsin, castor oil) but remember balsam of peru is proinflammatory. 9. Consult WOCN if available.

3. Assess for thrush (oral fungal infection) and ask for treatment if present. 4. For women with fungal rash, ask health care provider to evaluate for vaginal fungal infection and ask for treatment if needed. 5. Assess skin folds, including under breasts, under pannus, and in groin. 6. If no improvement, culture area for possible bacterial infection.

Prevalon® Pressure-Relieving Heel Protector with Integrated Foot and Leg Stabilizer Wedge Goes on in seconds for a secure, comfortable fit

HEEL PROTECTION

For use with calf circumference of 10”-18” (25cm-46cm)

Heel Pressure Ulcer Staging Guide

1

Pull boot up around foot.

2

Adjust Wedge.

3

Wrap stretch panels around boot.

4

Adjust straps. Do not overtighten.

To reorder, contact Sage Customer Service 800-323-2220 www.sageproducts.com 21251C © Sage Products Inc. 2011

#7355 reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

HEEL PROTECTION Heel Pressure Ulcer Staging Guide

Simple Interventions. Extraordinary Outcomes.

* Developed by Christine Baker, RN, MSN, CWOCN, APN

Taken from Poster, Head Over Heels: Best Practices for Preventing Heel Ulcers, presented at the Symposium on Advanced Wound Care, San Diego, CA, April, 2008.

To reorder, contact Sage Customer Service

800-323-2220 www.sageproducts.com

21252C © Sage Products Inc. 2011

#7355 reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

see individual product package(s) for complete information

STEP 2: ORAL CLEANSING RECOMMENDATIONS

Score of 5

Score of 6 to 10

Score of 11 to 20

NO OBSERVED DYSFUNCTION,

MILD DYSFUNCTION

MODERATE TO SEVERE DYSFUNCTION

but at possible risk for alteration in integrity, function, or comfort of oral cavity.

of integrity, function, or comfort of oral cavity.

of integrity, function, or comfort of oral cavity.

1. Perform oral assessment on admission and once daily. 2. Remove and brush dentures 2 times daily (same time as oral care). 3. Perform oral care 4 times daily (after meals, at bedtime). 4. Use Ultra-Soft Toothbrush and Sodium Bicarbonate Mouthpaste to clean teeth, gums and entire oral mucosa.

1. Perform oral assessment on admission and 2 times daily (AM and PM). 2. Remove and brush dentures 2 times daily (same time as oral care); leave out if irritating. 3. Perform oral care 6 to 12 times daily. 4. Use Ultra-Soft Toothbrush and Sodium Bicarbonate Mouthpaste to clean teeth, gums and entire oral mucosa. If painful or risk of bleeding, use Toothette® Plus Swabs.

1. Perform oral assessment on admission and 3 times daily. 2. Remove dentures (and leave out). 3. Perform oral care 12 times daily. 4. Use Toothette® Plus Swabs and Sodium Bicarbonate Mouthpaste, Perox-A-Mint® Solution or Antiseptic Oral Rinse to clean teeth, gums and entire oral mucosa.

For patients requiring suction, use Suction Swabs or Suction Brushes. 5. Rinse with Perox-A-Mint® Solution, Antiseptic Oral Rinse or water. 6. Apply Mouth Moisturizer to lips and oral mucosa to lubricate and moisturize

For patients requiring suction, use Suction Swabs or Suction Brushes. 5. Rinse with Perox-A-Mint® Solution, Antiseptic Oral Rinse or water. 6. Apply Mouth Moisturizer to lips and oral mucosa to lubricate and moisturize (frequently; after oral care and 4 times daily minimum).

Product Reorder #s

Product Reorder #s

ORAL HYGIENE Oral Cavity Assessment Tool and Recommended Care Guide

For patients requiring suction, use Suction Swabs or Suction Brushes. 5. Rinse with Perox-A-Mint® Solution, Antiseptic Oral Rinse or water. 6. Apply Mouth Moisturizer to lips and oral mucosa to lubricate and moisturize (every 1 to 2 hours; after oral care and as needed).

Product Reorder #s

xxxx reorder #

Directions:

begin upon admission

STEP 1: ORAL ASSESSMENT

• Determine rating for each category. • Add up ratings. • Implement interventions based on total score. Note: Use Universal Precautions during oral assessment and intervention. Refer to your facility policy and procedure for oral cavity exams. With all oral care, be especially cautious to prevent aspiration with patients who have a compromised gag reflex. If assessment determines a potential need for cultures, protective agents, topical anesthetics or medications, consult a physician. Adapted with permission from Beck, S.L., Oral Exam Guide 1991.

Simple Interventions. Extraordinary Outcomes. To reorder, contact Sage Customer Service

800-323-2220 www.sageproducts.com 21299C © Sage Products Inc. 2011

CATEGORY

1

2

3

4

RATING

Smooth, pink, moist, and intact

Slightly wrinkled and dry; one or more isolated reddened areas

Dry and somewhat swollen; may have one or two isolated blisters; inflammatory line of demarcation

Extremely dry and edematous; entire lip inflamed; generalized blisters or ulceration

1 2 3 4

Smooth, pink, moist, and intact

Pale and slightly dry; one or two isolated lesions, blisters, or reddened areas

Dry and somewhat swollen; generalized redness; more than two isolated lesions, blisters, or reddened areas

Extremely dry and edematous; entire mucosa very red and inflamed; multiple confluent ulcers

1 2 3 4

Smooth, pink, moist, and intact

Slightly dry; one or two isolated reddened areas; papillae prominent particularly at base

Dry and somewhat swollen; generalized redness but tip and papillae are redder; one or two isolated lesions or blisters

Extremely dry and edematous; thick and engorged; entire tongue quite inflamed; tip very red and demarcated with coating; multiple blisters or ulcers

Teeth

Clean; no debris

Minimal debris; mostly between teeth

Moderate debris clinging to half of visible enamel

Covered with debris

1 2 3 4

Saliva

Thin, watery, plentiful

Increased in amount

Scanty; may be thicker than normal

Thick and ropy, viscid, or mucoid

1 2 3 4

Lips

Gingiva and oral mucosa Tongue

See back for recommended oral care summaries.

TOTAL SCORE:

1 2 3 4

Prevalon® Petite Pressure-Relieving Heel Protector Goes on in seconds for a secure, comfortable fit

HEEL PROTECTION

For use with calf circumference of 6”-10” (15cm-25cm) and for feet smaller than 9.31 in. / 23.65 cm in length

Heel Pressure Ulcer Staging Guide

(Inside out) Do not overtighten straps

Sequential compression device compatible. Make sure tubing is not kinked or compressed against patient’s skin.

1

Pull boot up around foot.

2

Make sure patient’s heel is floated.

Wrap stretch panels around boot.

3

Adjust straps. Do not overtighten.

To reorder, contact Sage Customer Service 800-323-2220 www.sageproducts.com 21362B © Sage Products Inc. 2011

#7310/#7312 reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Prevalon® XL Pressure-Relieving Heel Protector with Integrated Foot and Leg Stabilizer Wedge Goes on in seconds for a secure, comfortable fit

HEEL PROTECTION

For use with calf circumference of 18”-24” (46cm-61cm)

Heel Pressure Ulcer Staging Guide

1

Pull boot up around foot.

2

Adjust Wedge.

3

Wrap stretch panels around boot.

4

Adjust straps. Do not overtighten.

To reorder, contact Sage Customer Service 800-323-2220 www.sageproducts.com 21363B © Sage Products Inc. 2011

#7382 reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

HEEL PROTECTION Heel Pressure Ulcer Staging Guide

Simple Interventions. Extraordinary Outcomes.

* Developed by Christine Baker, RN, MSN, CWOCN, APN

Taken from Poster, Head Over Heels: Best Practices for Preventing Heel Ulcers, presented at the Symposium on Advanced Wound Care, San Diego, CA, April, 2008.

To reorder, contact Sage Customer Service

800-323-2220 www.sageproducts.com

#7300 21617 © Sage Products Inc. 2011

reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

HEEL PROTECTION Heel Pressure Ulcer Staging Guide

Simple Interventions. Extraordinary Outcomes.

* Developed by Christine Baker, RN, MSN, CWOCN, APN

Taken from Poster, Head Over Heels: Best Practices for Preventing Heel Ulcers, presented at the Symposium on Advanced Wound Care, San Diego, CA, April, 2008.

To reorder, contact Sage Customer Service

800-323-2220 www.sageproducts.com

21618 © Sage Products Inc. 2011

#7310/#7312 reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

HEEL PROTECTION Heel Pressure Ulcer Staging Guide

Simple Interventions. Extraordinary Outcomes.

* Developed by Christine Baker, RN, MSN, CWOCN, APN

Taken from Poster, Head Over Heels: Best Practices for Preventing Heel Ulcers, presented at the Symposium on Advanced Wound Care, San Diego, CA, April, 2008.

To reorder, contact Sage Customer Service

800-323-2220 www.sageproducts.com

#7382 21619 © Sage Products Inc. 2011

reorder #

STAGE 2

STAGE 3

Partial thickness loss of dermis; presents as shallow open ulcer with a red pink wound bed, no slough present. May be an intactor open/ruptured serum-filled blister.

Full thickness tissue loss. May be able to see subcutaneous fat; can NOT see bone, tendon or muscle. Slough may be present but you can still see the depth of tissue loss. Undermining and tunneling may be present.

Copyright © 2008 Evonne Fowler, RN, CNS, CWOCN and Suzy Scott, RN, MSN, CWOCN. Head Over Heels: Best Practices for Preventing Heel Ulcers, poster presented at the Symposium on Advanced Wound Care, San Diego, CA April, 2008. All rights reserved. Reproduce with permission.

..........................................

Non-blanchable redness of intact skin in a localized area, usually over a bony prominence. Darkly pigmented skin may not blanch; its color may differ from surronging tissue.

..........................................

......................................

STAGE I

STAGE 4

UNSTAGEABLE

Full thickness tissue loss with exposed bone, tendon or muscle. May have slough or eschar but still can see base of wound. Undermining and tunneling often present.

Full thickness tissue loss but the wound bed is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black).

SUSPECTED DEEP TISSUE INJURY Local area of purple or maroon discolored in tact skin or blood-blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Prevalon Turn & Position System ®

Helps protect patients and staff! 1

Sacral Protection

• For single patient use only. • Weight capacity: 350 lbs./160 kg.

2

4

Instructions for Use & Staging Guide

5

Sacrum

1

1

3

Place Prevalon Turn and Position System under patient.

CAUTION:

2 3

Position 30-Degree Wedges to offload sacrum. Pull handles to turn patient.

• 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 & procedures. • Periodically check product for signs of wear. Replace if product is damaged.

4

Adjust head of bed to desired angle. Attach Anti- Shear Strap on Glide Sheet to Fastener Strip on bed frame.

5

Product stays under patient. Always ready for next turn.

To reorder, contact Sage Customer Service 800-323-2220 / www.sageproducts.com 21703 © Sage Products Inc. 2012

#7200 reorder#

Stage I:

Non-blanchable Erythema Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage II:

Partial Thickness of dermis Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister.

Reference: “European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention & Treatment of: Quick Reference Guide.” Washington, DC: National Pressure Ulcer Advisory Panel, 2009. Photos Used with permission of the National Pressure Ulcer Advisory Panel, March 2012

Stage III:

Full Thickness tissue Loss

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage IV:

Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling

Suspected Deep Tissue Injury –

Depth Unknown

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/ or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Prevalon Turn & Position System 2.0 ®

Helps protect patients and staff!

SACRAL PROTECTION

• For single patient use only. • Weight capacity: 550 lbs./250 kg.

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1

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.

2

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.

CAUTION:

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Roll patient away from you onto their side. Tuck Glide Sheet with Body Pad under patient and unroll toward you. Raise bed rail. Repeat on other side. Using black handles, align the patient’s hips with the hip indicator on the bed. Place Wedge with label side up. Lift edge of Glide Sheet and gently push wedge under patient, allowing Wedge to initiate patient turning movement.

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Place Anchor Wedge with label side up. Grasp Anchor and slide under patient’s thighs. Wedges should be approximately 8 in/20 cm apart at the sacrum. Gently push Wedge under patient, allowing Wedge to initiate patient turning movement. Pull Anchor taut on other side of bed. 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.

• 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 & procedures. • Periodically check product for signs of wear. Replace if product is damaged.

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Instructions for Use & Staging Guide

To reposition patient, remove Body Wedges by grabbing corner and rotating wedge out. Refer to your facility’s protocol for frequency of repositioning. 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

To reorder, contact Sage Customer Service 800-323-2220 / www.sageproducts.com 22284 © 2014 Sage Products LLC

STAGE I:

NON-BLANCHABLE ERYTHEMA Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

STAGE II:

PARTIAL THICKNESS OF DERMIS Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister.

Reference: “European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention & Treatment of: Quick Reference Guide.” Washington, DC: National Pressure Ulcer Advisory Panel, 2009. Photos Used with permission of the National Pressure Ulcer Advisory Panel, March 2012

STAGE III:

FULL THICKNESS TISSUE LOSS

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

STAGE IV:

FULL THICKNESS TISSUE LOSS Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling

SUSPECTED DEEP TISSUE INJURY – DEPTH UNKNOWN

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/ or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Prevalon Turn & Position System ®

Helps protect patients and staff!

SACRAL PROTECTION

• For single patient use only. • Weight capacity: 800 lbs./362 kg.

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Mattress cover takes the place of fitted/flat sheet. Place the two black elastic corner straps around underside of mattress at head of bed.

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Attach all 4 black corner straps loosely. 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. Tighten all straps securely and make sure Mattress Cover is taut.

CAUTION:

3

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 towards you. Raise bed rail.

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Repeat on other side and center patient on bed. Attach Anti-Shear Strap on Glide Sheet to the Mattress Cover.

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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. First Wedge goes under patient’s back. Second Wedge goes under patient’s thigh. 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.

• 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 & procedures. • Periodically check product for signs of wear. Replace if product is damaged.

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Instructions for Use & Staging Guide

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. Adjust head of bed to desired angle.

To reorder, contact Sage Customer Service 800-323-2220 / www.sageproducts.com 22107 © Sage Products LLC 2013

STAGE I:

NON-BLANCHABLE ERYTHEMA Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

STAGE II:

PARTIAL THICKNESS OF DERMIS Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister.

Reference: “European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention & Treatment of: Quick Reference Guide.” Washington, DC: National Pressure Ulcer Advisory Panel, 2009. Photos Used with permission of the National Pressure Ulcer Advisory Panel, March 2012

STAGE III:

FULL THICKNESS TISSUE LOSS

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

STAGE IV:

FULL THICKNESS TISSUE LOSS Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling

SUSPECTED DEEP TISSUE INJURY – DEPTH UNKNOWN

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/ or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Prevalon Seated Positioning System Helps protect patients and staff ®

SACRAL PROTECTION

• For single patient use only. • Weight capacity: 350 lbs/160 kg

Instructions for Use & Staging Guide 1

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Sacral Sitting

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Prior to Positioning Patient: Position chair with space behind the chair for clinician(s) access. Lock chair brakes. Place SPS on chair seat, with product tag at the back of the seat, facing up. Tuck slightly into chair crease. The clear air chambers should be in direct contact with the chair surface.

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Make sure the top layer of SPS is fully extended over the front of the seat. Keep handles accessible (not under patient). Cover SPS with the Microclimate Management Pad.

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Patient Positioning: Following patient handling policy/ procedures, assist patient onto chair and SPS.

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When patient is safely seated, brace a foot or leg on the back of the chair for support. Simultaneously pull handles until the patient slides back into chair, in the upright seated position. Secure handles behind chair so they are safely out of the way.

Proper Sitting

CAUTION:

• DO NOT use Prevalon Seated Positioning System to lift patients. • Patient repositioning should always be performed following your facility’s safe patient handling policies & procedures. • Periodically check product for signs of wear. Replace if product is damaged. • DO NOT launder. Wipe clean with a damp cloth. • Only use with standard hospital chair, or rolling chair with brakes. • Not recommended for use with a wheelchair.

To reorder, contact Sage Customer Service 800-323-2220 / www.sageproducts.com 22185 © Sage Products LLC 2013

STAGE I:

NON-BLANCHABLE ERYTHEMA Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

STAGE II:

PARTIAL THICKNESS OF DERMIS Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister.

Reference: “European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention & Treatment of: Quick Reference Guide.” Washington, DC: National Pressure Ulcer Advisory Panel, 2009. Photos Used with permission of the National Pressure Ulcer Advisory Panel, March 2012

STAGE III:

FULL THICKNESS TISSUE LOSS

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

STAGE IV:

FULL THICKNESS TISSUE LOSS Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling.

SUSPECTED DEEP TISSUE INJURY – DEPTH UNKNOWN

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/ or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.