The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed
The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation? a. Friction
b. Shear
c. Moisture
d. Tunneling
B
Shear is the force exerted against the skin while the skin remains stationary and the bony structures move. For example, when the head of the bed is elevated, gravity causes the bony skeleton to pull toward the foot of the bed, while the skin remains against the sheets. Friction is surface damage caused by the skin rubbing against another surface that often results in an abrasion. Friction would result if the patient is dragged across the sheets. Skin moisture increases the risk for ulcer formation as moisture softens the skin and reduces its resistance to other physical factors such as pressure or shear. Moisture comes from many sources such as wound drainage, perspiration, and/or fecal and urinary incontinence. With continuous pressure over the area, deep tissue destruction continues, which often results in larger pockets of necrotic tissue beneath the opening of the main wound that resemble a tunnel; this is referred to as tunneling.
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