Skin tears

Best practices for care and prevention

INSTRUCTIONS Skin tears: Best practices for care and prevention

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Skin tears: Best practices for care and prevention

GENERAL PURPOSE: To present best practice recommendations for the prevention and management of skin tears. LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to: 1. Identify the risk factors for skin tears. 2. Describe components of the ISTAP tool kit. 3. List recommendations for best nursing practice related to skin tears.

1. A skin tear is a separation of skin layers caused by shear, friction, and/or
1. heat.
2. blunt force.
3. puncture.
4. chemical reaction.
2. A skin tear with separation of the epidermis from the dermis is considered
1. stage I.
2. superficial.
3. partial thickness.
4. full thickness.
3. ISTAP recommends that the Skin Tear Risk Assessment Pathway be used
1. upon admission and when a patient's health status changes.
2. every shift while a patient remains at risk.
3. only with patients over age 65.
4. only with patients who've been predetermined to be at risk.
4. According to the Skin Tear Risk Assessment Pathway, which of the following is an indication that a patient is athigh risk for skin tears?
1. previous skin tears
2. a lighter natural skin color
3. UV light exposure
4. dysplastic nevi
5. Which ISTAP tool kit component is the best choice for matching wound assessment, classification and product selection?
1. ISTAP Skin Tear Classification
2. Prevalence Study Data Collection Sheet
3. Skin Tear Decision Algorithm
4. Skin Tear Risk Assessment Pathway
6. The ISTAP classification of a skin tear with exposure of the entire wound bed is
1. type 1: no skin loss.
2. type 2: partial flap loss.
3. type 3: total flap loss.
4. unstageable.
7. All of the following are components of the ISTAP tool kitexcept
1. Prevalence Study Data Collection Sheet.
2. Braden Scale for Predicting Pressure ore Risk.
3. Drugs Associated with Risk of Falls.
4. Skin Tear Product Selection Guide.
8. When evaluating strength of evidence, an ISTAP recommendation that is based solely on expert opinion is
1. Level A.
2. Level B.
3. Level C.
4. Level D.
9. Patients with decreased sensory perception should avoid wearing
1. rubber-soled slippers.
2. clothing with drawstrings.
3. clothing with zippers.
4. sneakers with hook-and-loop fasteners.
10. The risk of self-injury resulting in skin tears is increased for patients with
1. dementia.
2. euvolemia.
3. normoglycemia.
4. normal coagulation.
11. The primary focus in skin tear prevention for neonates should be
1. cleansing wounds.
2. caregiver education.
3. appropriate clothing selection.
4. nutritional support.
12. Monitoring serum albumin and prealbumin levels helps the nurse assess
1. cognitive impairment.
2. hydration.
3. nutritional status.
4. sensory perception.
13. What's been shown to reduce overall fall risk by more than 20%?
1. physical restraints
2. maintenance of optimal body mass index
3. patient and family education
4. calcium and vitamin D supplementation
14. Epidermal regeneration and collagen synthesis is most commonly disrupted by
1. antipsychotic drugs.
2. corticosteroids.
3. antiepileptic drugs.
4. diuretics.
15. Pervin's research showed an increased fall risk among those receiving
1. insufficient nutritional supplements.
2. psychoactive drugs.
3. four or more medications.
4. two or more medications.
16. In a study by White et al., most skin tears were found to occur between the hours of
1. 0400 and 0800.
2. 0600 and 1100.
3. 1200 and 1400.
4. 2100 and 2300.
17. The ISTAP risk reduction program recommends knee-high socks to prevent skin tears related to
1. impaired mobility.
2. peripheral neuropathy.
3. altered sensory function.
4. cognitive impairment.
18. Patients who are independent in ambulation report high numbers of skin tears on their
1. hands.
2. upper extremities.
3. head and neck.
4. lower extremities.
19. According to a 2011 survey, which of the following was perceived as a top cause of skin tears?
1. shaving
2. brushing hair
3. dressing removal
4. ambulating with assistance
20. A good choice for skin cleansing or moisturizing the fragile skin of an older adult is
1. antibacterial soap.
2. cream moisturizer.
3. moisturizing lotion.
4. alkaline soap.
21. A head-to-toe skin tear risk assessment should be completed
1. once during hospitalization.
2. by unlicensed assistive personnel during routine care.
3. when prescribed by the healthcare provider.
4. using validated risk assessment tools.
22. McCarthy et attribute most injury and death among Americans 65 and older to
1. falls.
2. car crashes.
3. medication errors.
4. dementia.
23. Predisposing factors for falls include
1. active lifestyle.
2. use of rubber-soled slippers.
3. exercise.
4. dementia.
24. Skin changes typical in older adults include
1. increased skin elasticity.
2. epidermal thickening.
3. subcutaneous tissue loss.
4. increased skin surface moisture.
25. Compared with adults, neonates have
1. increased epidermal-to-dermal cohesion.
2. impaired thermoregulation.
3. thicker stratum corneum.
4. decreased body surface-to-weight ratio.
26. The number one cause of skin tears among neonates is
1. dehydration.
2. sudden weight changes.
3. malnutrition.
4. mechanical trauma.
27. Loss of subcutaneous fat in the hands, shins, and feet
1. increases energy absorbed by the skin during trauma.
2. protects bony prominences from blunt force.
3. masks ecchymoses.
4. increases cutaneous elasticity.
28. Senile purpura in older adults results from
1. collagen loss.
2. muscle atrophy.
3. inflammation.
4. fragile blood vessels.
29. A decrease in elastin fibers in the skin causes
1. increased tensile strength and increased elasticity.
2. decreased tensile strength and decreased elasticity.
3. decreased tensile strength and increased elasticity.
4. increased tensile strength and decreased elasticity.
30. Flattening of rete ridges causes a reduction of
1. xerosis cutis.
2. skin layer separation.
3. epidermis-to-dermis anchoring.
4. shearing susceptibility.
31. When managing a new skin tear, the nurse's first priority is to
1. clean the skin tear.
2. manage the patient's pain.
3. assess the skin tear.
4. remove the skin flap.
32. TIG should be administered
1. routinely with each skin tear.
2. if the wound appears infected.
3. after debridement of the skin tear.
4. if indicated according to facility protocol.
33. Which of the following statements regarding skin tear management is true?
1. Remove debris.
2. Maintain a dry wound bed.
3. Cleanse the wound with diluted hydrogen peroxide.
4. Remove all skin flaps.
34. Appropriate dressings for a skin tear include
1. hydrocolloids.
2. alginate.
3. adherent gauze mesh.
4. transparent film dressings.
35. The ISTAP tool kit was designed to be used
1. primarily in long-term-care facilities.
2. only in acute care hospital settings.
3. primarily by physicians and wound care specialists.
4. by all levels of staff and caregivers.

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