SEM 580 MODULE II UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS
Question:
Skin Tear Definition
Answer:
Traumatic wound caused by mechanical forces (friction, shear, &/or blunt force),
including removal of adhesives-(MARSI)
Top down injury
Question:
Partial thickness vs full thickness skin tear
Answer:
Partial thickness = separation of epidermis from dermis
Full thickness = separation of both epidermis and dermis from underlying
structures
depends on shear stress and strain forces
Question:
2 components of shear (stress vs strain)
Answer:
Shear stress = amount of force on the body or surface exerted PARALLEL to the
surface of the skin
Shear Strain = amount of distortion of tissues due to stress
Question:
Skin tear risk factors - skin
Answer:
Age extremes, female, caucasian, previous skin tear, presence of bruising, use of
medical adhesives or devices, blood draws
Question:
Skin tear risk factor - General health
Answer:
decreased cognition, sensory, visual, and auditory status, malnutrition,
dehydration, comorbidities (cardiovascular, pulmonary, incontinence,
anticoagulants, etc.)
Question:
Maintain skin health -
Identify frail skin, skin tear hx, reassess as condition changes
No rinse pH balance cleanser
Moisturizer BID
Avoid sharp nails and jewelry
Safe measures for adhesive use/removal or use alternatives
Optimize mobility and safe environment-
, mechanical lifts/slings
well-fitted shoes
protective garments for extremities
Remove room obstacles
Pad edges of furniture, secure rugs,
Improve general health -
Adequate hydration and nutrition
Optimize sensory perception
Manage peripheral edema
Consider effects of polypharmacy
Answer:
Skin tear interventions (3)
Question:
ISTAP - Type 1 Skin tear
Answer:
No skin loss
Linear or flap tear that can be repositioned to cover the wound bed
Can be fully reapproximated
Question:
ISTAP - Type 2 Skin tear
Answer:
Partial flap loss
Partial flap loss that cannot be repositioned to cover the entire wound bed
Question:
ISTAP - Type 3 skin tear
Answer:
Complete flap loss
Total flap loss exposing the entire wound bed
Question:
Control bleeding
Approximate viable tissue
Select non-adherent or low-adhesive with high MVTR (moisture vapor
transmission rate) dressing to maintain moist wound bed (not too dry or too wet),
secure with wrap or roll gauze to minimize potential for trauma and frequency of
dressing removal.
Consider arrow on dressing for removal direction to prevent flap disruption
Consider skin barrier film to periwound area
Avoid transparent films, skin closure strips, and gauze
Dressing selection based on amount of exudate to minimize dressing frequency
Answer:
Skin tear treatment
Question:
AND CORRECT ANSWERS
Question:
Skin Tear Definition
Answer:
Traumatic wound caused by mechanical forces (friction, shear, &/or blunt force),
including removal of adhesives-(MARSI)
Top down injury
Question:
Partial thickness vs full thickness skin tear
Answer:
Partial thickness = separation of epidermis from dermis
Full thickness = separation of both epidermis and dermis from underlying
structures
depends on shear stress and strain forces
Question:
2 components of shear (stress vs strain)
Answer:
Shear stress = amount of force on the body or surface exerted PARALLEL to the
surface of the skin
Shear Strain = amount of distortion of tissues due to stress
Question:
Skin tear risk factors - skin
Answer:
Age extremes, female, caucasian, previous skin tear, presence of bruising, use of
medical adhesives or devices, blood draws
Question:
Skin tear risk factor - General health
Answer:
decreased cognition, sensory, visual, and auditory status, malnutrition,
dehydration, comorbidities (cardiovascular, pulmonary, incontinence,
anticoagulants, etc.)
Question:
Maintain skin health -
Identify frail skin, skin tear hx, reassess as condition changes
No rinse pH balance cleanser
Moisturizer BID
Avoid sharp nails and jewelry
Safe measures for adhesive use/removal or use alternatives
Optimize mobility and safe environment-
, mechanical lifts/slings
well-fitted shoes
protective garments for extremities
Remove room obstacles
Pad edges of furniture, secure rugs,
Improve general health -
Adequate hydration and nutrition
Optimize sensory perception
Manage peripheral edema
Consider effects of polypharmacy
Answer:
Skin tear interventions (3)
Question:
ISTAP - Type 1 Skin tear
Answer:
No skin loss
Linear or flap tear that can be repositioned to cover the wound bed
Can be fully reapproximated
Question:
ISTAP - Type 2 Skin tear
Answer:
Partial flap loss
Partial flap loss that cannot be repositioned to cover the entire wound bed
Question:
ISTAP - Type 3 skin tear
Answer:
Complete flap loss
Total flap loss exposing the entire wound bed
Question:
Control bleeding
Approximate viable tissue
Select non-adherent or low-adhesive with high MVTR (moisture vapor
transmission rate) dressing to maintain moist wound bed (not too dry or too wet),
secure with wrap or roll gauze to minimize potential for trauma and frequency of
dressing removal.
Consider arrow on dressing for removal direction to prevent flap disruption
Consider skin barrier film to periwound area
Avoid transparent films, skin closure strips, and gauze
Dressing selection based on amount of exudate to minimize dressing frequency
Answer:
Skin tear treatment
Question:
