# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=364219&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

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.

1

Keep heels elevated off the bed surface using a pillow or foam device

2

Reposition every 2 hours when the client is in bed

3

Use moisture-wicking under-pads to manage urinary incontinence

4

Elevate the head of the bed to 45 degrees with knees flexed

5

Massage reddened areas firmly to improve circulation

6

Inspect the skin daily and reassess pressure-injury risk with the Braden Scale per policy and condition changes.

## 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.

## In-depth explanation

Clinical Judgment
Pressure injury prevention SSKIN bundle: Surface, Skin inspection, Keep moving, Incontinence/moisture, Nutrition. Reposition q2h, heel offloading, HOB ≤30 unless medically required higher, moisture-wicking pads, daily Braden score.

Memory Tip
SSKIN: Surface + Skin + Keep moving + Incontinence + Nutrition

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 scenario

Clinical Practice Guide
NPIAP/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

Caution
Stage 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.

## Key concepts

- **Braden Scale** — Validated 6-item pressure injury risk assessment: sensory perception, moisture, activity, mobility, nutrition, friction/shear. Score 6-23. Lower = higher risk. Cutoffs vary; commonly 15-18 mild, 13-14 moderate, 10-12 high, ≤9 very high.
- **Pressure injury staging** — NPIAP 2016: Stage 1 (intact red), Stage 2 (partial-thickness skin loss), Stage 3 (full-thickness skin loss exposing fat), Stage 4 (full-thickness exposing muscle/bone), unstageable (covered by slough/eschar), deep tissue injury (intact maroon discoloration).
- **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.

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