A nurse is creating a pressure injury prevention plan for an immobile older adult admitted after a stroke who has urinary incontinence and a Braden score of 12. Which interventions are evidence-based components of the SSKIN bundle? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
The SSKIN approach includes an appropriate support Surface, regular Skin inspection, Keeping the client moving, managing Incontinence and moisture, and supporting Nutrition and hydration. Use a pressure-redistributing surface and offload the heels (Choice 2). Cleanse promptly after incontinence and apply a moisture barrier or skin protectant (Choice 3). Use an individualized repositioning plan with frequent small shifts and a 30-degree lateral tilt; for this immobile high-risk client, an initial schedule of at least every 2 hours is appropriate and should be adjusted to skin response and tolerance (Choice 4). Do not massage nonblanching redness over bony prominences because this can worsen tissue injury (Choice 5). Do not use donut or ring cushions because they can concentrate pressure and impair tissue perfusion (Choice 6). Repositioning only every 4 hours while maintaining a supine position leaves prolonged pressure on the sacrum and heels (Choice 1).
Memory Tip "SSKIN" prevention bundle. Avoid: massaging redness, donut cushions, prolonged head of bed > 30 degrees (shear).
Caution Stage I redness that does NOT blanch on pressure indicates impending pressure injury. Document, offload area immediately, and re-evaluate intervention plan.
Scenario82 y.o., post-stroke, dense right hemiparesis, urinary incontinence, low intake. Admitted 24 hr ago. Skin: pink areas over sacrum that blanch with pressure. Braden 12 (high risk). Albumin 2.8.
When to EscalateStage I non-blanching erythema, Stage II partial-thickness loss, or any deep tissue injury → wound care nurse consult, photo documentation, intensified offloading.
SSKIN bundle — Evidence-based pressure injury prevention bundle: Surface (pressure-redistributing), Skin inspection, Keep moving (reposition q2h, 30-degree tilt), Incontinence (skin care + barrier), Nutrition (adequate protein/calories/fluid). Endorsed by NPIAP, EPUAP, and adopted in most acute and long-term care settings.
Braden Scale — Validated pressure injury risk assessment with 6 subscales: sensory perception, moisture, activity, mobility, nutrition, friction/shear. Total score 6-23. Lower scores indicate higher risk: ≤9 very high, 10-12 high, 13-14 moderate, 15-18 mild. Reassess on admission, every shift, and with status change.
Practices to AVOID — Massaging reddened bony prominences (damages capillaries), donut/ring cushions (cause venous congestion and worsen central pressure), prolonged head of bed > 30 degrees (shear forces on sacrum), and dragging the client during repositioning (friction and shear). All increase pressure injury risk.