A nurse is caring for a 75-year-old client with limited mobility and urinary incontinence on a medical-surgical unit. Which interventions are part of the evidence-based pressure injury prevention bundle? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
The prevention bundle includes heel offloading, regular repositioning individualized to the client, moisture management, systematic skin inspection, and standardized pressure-injury risk reassessment. The Braden Scale estimates pressure-injury risk; it does not replace a head-to-toe skin assessment. Firm massage of reddened tissue may worsen injury, and unnecessary head-of-bed elevation increases shear.
KR vs U NPIAP/EPUAP international guideline (2019) and Korean Wound, Ostomy and Continence Nurses Society guidelines align: 2-hour repositioning, Braden Scale, no massage of reddened areas, heel offloading, support surfaces.
Clinical Practice GuideNPIAP/EPUAP/PPPIA 2019 prevention bundle:- Reposition every 2 hours when in bed; q1h if in chair- 30-degree side-lying tilt instead of full lateral to reduce trochanter pressure- Heel offloading: pillows under calves or commercial heel boots- HOB ≤30 degrees unless aspiration risk or respiratory needs- Moisture management: clean and dry skin promptly after incontinence; barrier cream- Daily Braden Scale; cutoff varies, <18 high risk- Pressure-redistributing mattress for high-risk clients- Adequate hydration and protein intake
CautionStage 1 (intact red skin) and Stage 2 (partial-thickness) injuries are reversible if pressure is removed. Stage 3, 4, unstageable, and deep tissue injury require wound care and may require surgical debridement. Document staging accurately for quality reporting.
Heel offloading — Lifting the heels off the bed surface to eliminate pressure on a high-risk pressure injury site. Achieved with pillows under calves, commercial heel boots, or wedges. Critical for clients with diabetes, vascular disease, or paraplegia.