The Importance of Skin Assessment in Pressure Ulcer Preventative Care Plans

The regular inspection of patients’ skin to check for any abnormalities is key to effective pressure ulcer prevention and treatment.

This ensures that even if there is no formal risk assessment tool in place, any changes in the skin’s appearance will alert healthcare professionals that there is a heightened risk that could be forewarning oncoming deep pressure damage.

Non-blanchable erythema (also called NBE) is a persistent discoloring of the skin that will not turn white if it is pressed on. This is a clinically urgent abnormality of the skin that should be identified as part of a thorough inspection. NBE is a sign that the skin is in a state of deterioration and should trigger an individualized pressure ulcer preventative care plan.

Skin; image source:

A patient with NBE is more apt to develop a new PU than a patient that does not have NBE. Clinicians should perform a full skin assessment if NBE is present and formulate a preventative care plan tailored specifically for that patient.

Nursing staff both in facilities and performing in-home care and all other clinicians must have a firm grasp of the key concepts of skin assessment so that they can understand thoroughly and discuss the risk factors of impaired skin integrity with their patient. Identification of existing health conditions that can have a cause or affect of the skin integrity is also important. All clinicians should have a comprehension of evidence-based skin intervention and be able to relay and discuss these interventions with their patients in a manner that is understandable.

Avoidance of medical terminology is key to being sure that your patient understands without insulting his/her intelligence. This all requires knowledge of the anatomy of human skin. With this knowledge comes an understanding of how to assess skin and care for it and it is of utmost importance when properly categorizing pressure ulcers.

Skin Assessment Steps

A systematic inspection of the patient’s skin should be performed from head to toe. Even though a PU will usually be found over areas of the body that are bony, they can also pop up in other places such beneath masks, oxygen cannulas, and catheters. Skin damage can also be caused by a patient lying on items that get lost in their bed or chair such as a remote control.

If a heavy patient is being assessed, attention should be given to the skin between or under the folds to see if there is any evidence of skin damage. Dignity and privacy should remain intact for the patient, and it is the practitioner’s responsibility to be sure that it does. If the patient has sound mental capacity, their express consent should be given prior to an assessment even being initiated.

The acronym BEST SHOT is from the UK pressure ulcer campaign called Stop The Pressure. BEST SHOT is a body specific acronym for the checkpoints of a visual assessment of a patient’s body for signs of compromised skin integrity and/or pressure ulcers.

  • Buttocks- being sure to check between the cheeks
  • Ears and Elbows
  • Sacrum (located near the coccyx which is also called the “tailbone”)
  • Trochanters (bony protuberances on the upper thigh bone)
  • Spine and Shoulders
  • Heels (especially if the patient is diabetic)
  • Occipital area (the bony area at the base of the cranium)
  • Toes

An optimal skin inspection guide for healthy skin should instruct clinicians to audit the most vulnerable areas of the body (BEST SHOT) and document any signs of pressure damage at least one time each day. Working this assessment into bathing or changing time is a good way to ease any discomfort the patient may feel about having their body examined.

Outlining the stages of risk can assist the clinician on whether or not to follow their intuition.

  • Pressure damage not seen. The patient should continue to be assessed on a daily basis. Be sure to encourage the patient and caregiver to consistently reposition the patient.
  • Signs of beginning pressure damage. The patient should be closely monitored and the clinician should discuss a prevention plan. The caregiver(s) needs to be a part of the plan and the team to prevent a pressure ulcer from setting in.
  • Evident sign(s) of pressure damage. A PU should be documented immediately according to facility/home healthcare provider direction. Treatment should be implemented immediately in order to halt the damage and keep it from spreading deep into the tissue. The general practitioner needs to be made aware and if there is a wound care specialist involved in the patient’s care, a consultation should be requested with them as well.

Skin Integrity Risks and What to Look For

Is the patient’s skin dry?

  • If so, assess whether or not the hydration problem is localized or systemically?
    • Does the patient have an existing skin condition that may be causing the dryness such as eczema or psoriasis?
      • What to do:
        • Monitor the patient’s intake of fluids (should be mostly water). Is he/she drinking enough to hydrate their body?
        • Is the patient on any medications that could be drying him/her out?
        • What type of soap is the patient being washed with? If the soap contains a large amount of perfumes, they may smell good but could be drying the patient’s skin severely.
        • Be sure that a moisturizer that is free of perfumes is being used to keep the sky hydrated after bathing.
      • Reason for importance:
        • When the skin is excessively dry, it is rough to the touch. This can cause an increase in friction that occurs when the skin touches any other surface (more specifically blankets and linens). Rough spots can tend to “catch” on fabrics.
        • Dry skin is prone to infections because the barrier function of the flesh is compromised greatly by having no moisture.

Is the patient’s skin excessively moist?

    • If so, does he/she have incontinence?
    • Does the patient have a high fever?
    • Is there a condition that causes him/her to drool? Is there saliva collected on the skin of the face, neck, or chest?
    • Is there a wound or a stoma (such as a tracheotomy) that is weeping?
    • Is the patient excessively sweating?
    • Is there localized edema in the patient?
      • What to do:
        • Be sure that the patient’s skin is kept dry and clean.
        • If it’s possible to manage the root cause of the excess fluid, the steps should be taken to do so.
        • Consider using a cream that will protect the skin, especially if incontinence is an issue and the patient is wearing a brief.
      • Reason for importance:
        • If the patient’s skin is excessively moist and exposed to wetness it will cause the skin to deteriorate.

Is the surrounding area cold compared to the rest of the body?

    • Has the patient been left in the same position for more than four hours?
    • Is the patient actually cold, or does he/she need to be covered up?
      • What to do:
        • Cold is an indicator of necrosis (death of the tissue). Check the body thoroughly for any additional symptoms of skin that is damaged.
        • Implement and navigate a repositioning plan. The area of concern should be completely offloaded, bearing no pressure.
      • Reason for Importance:
        • If tissue is hypoxic (lacking in oxygen) or has died this means that the working blood supply is non-existent and localized necrosis is a strong possibility.

Is the affected area hot compared to the skin on the rest of the body?

    • Is the heat a side effect of a localized infection?
    • Is there inflammation?
  • What to do:
    • Perform a thorough check of the rest of the body or any other symptoms of skin damage.
    • Inflammation is the body’s initial response to hypoxia and at this stage it can be reversed if treated promptly.
  • Reason for importance:
    • When the body’s inflammatory response kicks in, blood flows to the area and the localized tissue can become red or discolored and warm.
    • Edema can end up getting into the area and the skin can get very tight and hard. Eventually there may be an issue with the area weeping due to the skin breaking from the swelling.

Are the affected red or discolored?

    • Does the red area blanch? When the flesh is pressed on, does it turn white momentarily after the pressure is released?
      • What to do:
        • Thoroughly check the body for any other signs or symptoms of skin damage.
        • If the affected area does not blanch when pressure is applied, then the NBE must be documented.
        • Initiate and implement a repositioning plan to keep pressure from being applied to the area.
      • Reason for importance:
        • Blood will flow to the affected area as part of the body’s natural inflammatory reaction. This will usually cause the local tissue to redden or discolor and feel warm to the touch. Temporary mild pressure applied to the area will trigger blanching if the blood flow is adequate. If the damage is permanent (NBE), then the flesh will remain reddened or discolored.
  • Is the skin boggy?
    • Does the patient have tenderness or pain that is localized?
    • Has the patient complained of a numb sensation in the locally affected area?
    • Does the skin have a dark purple color to it directly over the area?
      • What to do:
        • Thoroughly check the patient’s body for other signs of damage to the skin since boggy skin is an indicator the tissue is dead/dying and necrosis may be present.
        • Initiate and implement a repositioning plan to take the pressure off the affected area.
      • Reason for importance:
        • Even though the surface of the skin may seem as though it is intact, the textural change is likely an indicator may be lying in the deep tissues beneath the flesh. This is a heightened level of damage to the tissue.

Is the skin hard and tight?

    • Is there localized pain and tenderness in the area?
    • Is there any numbness?
    • Is the tightness a result of inflammation?
      • What to do:
        • Look over the patient’s entire body to see if there are any other signs of damage to the skin.
        • If discoloration or redness is present and the area of the skin will not blanch, immediately document NBE.
        • Initiate and implement a plan for repositioning to avoid further pressure on the affected area.
      • Reason for Importance:
        • The change in the texture of the skin indicates that an inflammatory reaction has been triggered and that there is localized edema present even though the skin is still intact.

Using a Body Map

It is beneficial to use a body map to document the positioning of any skin damage that is found during a risk assessment. A brief description of the area of damage should also be given. If possible, a picture of the area can be useful in properly depicting the size and severity of the skin damage. You must have express consent from the patient for the pictures to be taken. Be sure to find out what the policies are for your place of employment regarding photography. When taking a picture you should:

  • Take a broad shut for proper location of the wound.
  • Take a close shot to capture the wound details.
  • The background should be clear with no clutter.
  • Utilize a paper measuring tape placed next to the wound as an indicator of the wound size.

The Importance of Skin Care

The patient and caregiver should be instructed on the importance of keeping the patient’s skin clean and dry. A simple cleanser should be used for soap, free from perfumes or dyes. When drying the skin, it should be patted rather than rubbed.

If moisture is a risk, a skin barrier should be applied. Always encourage the patient to take an active role in inspecting their own skin and caring for it. Offer nutrition plans to the patient and be sure that he/she understands how important hydration is to maintaining healthy skin.

About the author:

Heidi West is a medical writer for Vohra Wound Physicians, a national wound care physician group. She writes about healthcare and technology in the medical industry.
















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