# 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.

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> language: en  
> subject: Basic Care and Comfort  
> category: BCC

## Question

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.

1

Use a pressure-redistribution support surface (low-air-loss or alternating pressure mattress) appropriate to the patient's risk level.

2

Offload the heels with pillows under the calves, floating the heels off the bed, OR use heel-protection boots; do NOT place pillows under the heels themselves.

3

Reposition the patient at least every 2 hours, and more frequently if redness persists; use the 30-degree lateral side-lying position rather than 90 degrees to reduce trochanter pressure.

4

Optimize nutrition with referral to dietary; ensure adequate protein, calories, and hydration to support skin integrity.

5

Massage reddened areas at least every 2 hours using gentle, circular motions to enhance local circulation and maintain skin integrity.

## 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."

## In-depth explanation

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 Both have been replaced by the modern bundle: reposition, offload, redistribute, nourish.

## Clinical scenario

**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.

## Key concepts

- **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.

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