A nurse is caring for an immobile, malnourished older adult at high risk for pressure injury (Braden score 12). Which interventions should the nurse implement as part of the pressure injury prevention bundle? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Pressure injury prevention bundle: reposition q2h with 30-degree lateral, offload heels with pillows under calves (floating heels — NEVER under heels themselves), pressure-redistribution mattress, nutritional optimization with protein/calories/hydration. Choice 5 is wrong — massaging areas of redness is contraindicated; it can damage already-compromised tissue and increase shearing forces. Current NPIAP/EPUAP guidelines explicitly say "do not massage."
Two old-textbook traps still on NCLEX: (1) "massage red areas" — wrong, may cause deep tissue injury; (2) "donut/ring cushions" — wrong, they redistribute pressure to a smaller area and worsen ischemia. Both have been replaced by the modern bundle: reposition, offload, redistribute, nourish.
Immobile, malnourished older adult on a med-surg unit. Braden score 12 (high risk). Albumin 2.6 g/dL. Skin is currently intact but fragile.
Braden Scale — Pressure injury risk assessment tool with 6 subscales; ≤ 12 = high risk, ≤ 9 = very high risk.
30-degree lateral position — Side-lying at 30 degrees rather than 90 degrees to avoid direct pressure on the trochanter.
Heel offloading — Float heels off the bed using pillows under the calves or heel-protection boots; never place pillows under the heels.