SKIN TEARS
This type of injury occurs when the skin is torn or pulled away, often due to friction or shear, especially common in older adults with fragile skin.
What is a skin tear?
Non-blanching erythema.
What is a stage one pressure ulcer.
This validated assessment tool, used to evaluate sensory perception, moisture, activity, mobility, nutrition, and friction/shear, is typically located in electronic health records and institutional protocols to guide individualized pressure injury prevention plans.
What is the Braden Scale for Predicting Pressure Sore Risk?
When assessing skin color in a patient with dark skin tones, nurses must do this to accurately detect changes such as pallor or cyanosis.
What is assessing the mucous membranes, conjunctiva, and nail beds rather than relying solely on skin color?
In most healthcare settings, this licensed professional is responsible for assessing the need and writing the order for a specialty pressure-relieving bed.
Who is the physician, nurse practitioner, or physician assistant?
An elderly patient has fragile, thinning skin and is at risk for skin tears. The nurse knows prevention requires understanding this mix of patient factors and environmental causes that make skin easily injured.
What are age-related skin changes (like less collagen and elasticity), medications such as steroids or blood thinners, limited mobility, and external factors like friction, shear, and rough handling?
Frequent and documented turns, sequential TEDs, heel elevation, skin assessment.
What is pressure ulcer precautions?
This nursing researcher and professor developed the widely used pressure ulcer risk assessment tool that evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Who is Barbara Braden?
A patient with diabetes presents with a shallow ulcer on the plantar surface of the foot. The nurse understands this is likely due to this pathophysiologic factor affecting skin integrity.
What is peripheral neuropathy causing loss of protective sensation and unrecognized trauma?
Braden Score of 9 with skin breakdown on the sacrum despite frequent repositioning. This intervention via SBAR will help to reduce further pressure injury.
What is notify the provider and advocate for a specialty bed, such as a low-air-loss or alternating pressure mattress?
Wound gel, adaptic, allevyn thin white
What are the different dressings for skin tears?
An 84-year-old patient with limited mobility, poor nutritional intake, and urinary incontinence is admitted to a medical-surgical unit. Based on these risk factors, the nurse prioritizes this comprehensive intervention plan to prevent pressure ulcer formation.
What is implementing a pressure injury prevention bundle, including frequent repositioning, use of barrier creams, nutritional support, and pressure-relieving surfaces?
6 and 23
What is the lowest and highest Braden scale.
During a skin assessment, the nurse finds a reddened area over the sacrum that does not blanch when pressed. The nurse recognizes this as a sign of this early-stage skin injury and takes these immediate actions.
What is a Stage 1 pressure injury; the nurse should relieve pressure, document findings, and implement prevention measures?
To qualify for a low-air-loss mattress, a patient typically must meet this condition, which includes having a high risk for pressure injuries or existing Stage 3 or 4 pressure ulcers, despite routine preventive interventions.
What is the presence of a high pressure ulcer risk (e.g., Braden Score ≤ 12) or an existing full-thickness pressure injury?
Skin Tear protocols are in place.
Why do most skin tears not require consultation with a WOCN?
Heels and coccyx.
What is the most frequent areas for pressure ulcers?
Skin assessment is to be done on admission and at least every 24 hours thereafter (or more frequently if the patient’s condition changes).
What is the recommended frequency for performing a Braden Scale assessment on hospitalized patients to monitor their risk status?
Note the size, depth, drainage, and surrounding tissue; notify the provider or wound care nurse; document thoroughly; and initiate appropriate wound care per facility protocol
What should the nurse do after discovering an open area on the patient’s skin during a skin assessment?
This type of specialty support surface uses fine grains to evenly distribute pressure by conforming to the patient’s body, often used historically but less common today due to maintenance challenges.
What is a sand bed?
Wound gel, adaptic, gauze and rolled gauze daily.
What is skin tear protocol example?
We own it.
If a pressure ulcer is not documented on admission.
A patient scores 12 on the Braden Scale. The nurse’s best next step is to do this comprehensive plan to prevent ulcers.
What is starting a prevention plan that includes frequent repositioning, using pressure-relieving devices, checking nutrition, caring for the skin, and regularly reassessing risk?
This combination of intrinsic and extrinsic factors—including immobility, poor nutrition, moisture, altered sensation, and impaired perfusion—places patients at significantly increased risk for developing pressure ulcers, especially in acute and long-term care settings.
What are the primary risk factors for pressure ulcer development?
This pressure-relieving device is placed on top of a standard hospital mattress and is often used for patients who cannot turn themselves in bed but are at mild to moderate risk for pressure injuries.
What is a pressure-relieving mattress overlay?