# 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. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568909&lang=en > language: en > subject: Personal Hygiene > category: BCC ## Question 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. 1 Keep the client supine with the head of the bed at 30 degrees or less and reposition only every 4 hours, regardless of skin findings or tolerance 2 Place the client on a pressure-redistributing support surface and use heel-offloading devices that suspend the heels off the bed 3 Cleanse the skin with a pH-balanced no-rinse cleanser after each incontinence episode and apply a moisture-barrier cream or skin protectant 4 Create an individualized repositioning schedule, initially at least every 2 hours, using frequent small shifts and a 30-degree lateral tilt rather than direct pressure on the trochanter 5 Gently massage reddened areas over bony prominences for 5 minutes each time the client is repositioned to stimulate blood flow 6 Place a donut-shaped cushion or ring under the client's sacrum during sitting periods to redistribute pressure and prevent skin breakdown ## 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). ## In-depth explanation SSKIN Bundle Surface — pressure-redistributing mattress + heel offloading Skin inspection — head-to-toe q shift, focus on bony prominences Keep moving — reposition q2h, 30-degree lateral tilt, mobilize ASAP Incontinence/moisture — pH-balanced cleanser, barrier cream, prompt change Nutrition — protein 1.2-1.5 g/kg/day, adequate calories, hydration, supplements PRN Risk Assessment — Braden Scale 6 subscales (sensory, moisture, activity, mobility, nutrition, friction). Scores: ≤9 very high, 10-12 high, 13-14 moderate, 15-18 mild risk. Lower score = higher risk. 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. ## Clinical scenario Scenario 82 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. SSKIN Plan - Surface: low-air-loss mattress; heel boots - Skin: q shift head-to-toe with photos PRN; check Braden q24h - Keep moving: q2h reposition (turn schedule posted), 30° tilt, OOB to chair PT 2× day - Incontinence: q2h check, pH cleanser, dimethicone barrier; consider external collection device - Nutrition: dietitian consult, protein 1.5 g/kg/day target, oral nutrition supplement BID, hydration 1.5 L/day When to Escalate Stage I non-blanching erythema, Stage II partial-thickness loss, or any deep tissue injury → wound care nurse consult, photo documentation, intensified offloading. ## Key concepts - **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. ## Related questions - [A hospice nurse is planning pain management for a client with metastatic cancer who can ta…](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=en) - [A nurse is creating a pressure injury prevention plan for an immobile older adult admitted…](https://mymerci.kr/pages/nclex_q.php?qn_id=366392&lang=en) - [A dying client's family asks to perform meaningful spiritual and cultural rituals at the b…](https://mymerci.kr/pages/nclex_q.php?qn_id=368302&lang=en) - [A nurse cares for family members after a loved one is told that an illness is terminal. Wh…](https://mymerci.kr/pages/nclex_q.php?qn_id=368324&lang=en) - [A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg…](https://mymerci.kr/pages/nclex_q.php?qn_id=369152&lang=en) - [A community health nurse is leading an advance care planning education session at a senior…](https://mymerci.kr/pages/nclex_q.php?qn_id=372705&lang=en) - [Stage 4 — Generate solutions. Select all nursing actions that belong in Mr. K's individual…](https://mymerci.kr/pages/nclex_q.php?qn_id=372807&lang=en) - [Stage 5 — Take action. Place the five nursing actions in the safest sequence for the initi…](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=568909&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=568909&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=568909&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=568909&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=568909&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._