Skin Integrity And Wound Care Study Guide Rated A+

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces? a) a client who lies on wrinkled sheets b) a client who lifts himself up on his elbows c) a client sitting in a chair who slides down d) a client who must remain on his back for long periods of time {Ans: a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a