3 Skin Assessment
Learn how to inspect and assess skin, recognize concerning changes, document findings clearly, and respond to new skin or tissue changes.
Conduct a systematic inspection
A combines visual examination, comparison with surrounding skin, and—when appropriate—gentle . Ask the person about localized pain or tenderness, since their report can add important information to what is seen and felt.
Inspect for breaks in the skin, color changes, moisture or maceration, and other visible abnormalities. Compare the area with nearby skin or the corresponding area on the other side of the body.
Check high-risk areas and tissue changes
Pay particular attention to , the skin beneath and around medical devices, and skin folds. These areas should be included in a systematic examination rather than relying on a quick look at exposed skin alone.
When appropriate, gently palpate for differences in temperature, texture, or firmness. Compare findings with nearby or corresponding skin, and ask about localized pain or tenderness.
Recognize changes beyond redness
Do not rely on visible redness alone. Color changes can be less apparent or look different in medium-to-dark skin tones, so compare the area with the person’s usual skin tone and surrounding skin.
Also assess for warmth or coolness, swelling, altered firmness, and pain. A new, persistent color change or another tissue change warrants attention even when redness is not obvious.
An area can be concerning even if the skin is intact. For example, localized warmth and increased firmness over one heel compared with the other may be an early warning sign. Assess further, avoid pressure on the area when possible, document the finding, and report or escalate it according to the care setting’s procedure.
Document findings clearly
Useful records the assessment date and time, anatomical location, whether the skin is intact, and objective observations. Describe color in comparison with surrounding skin, temperature, texture or firmness, moisture, and any tenderness or pain.
For an open wound, document measurements and relevant features, including , edges, drainage, and surrounding skin. Use clear, descriptive language and follow local documentation procedures. Record only details that were actually assessed.
Instead of a vague note such as “Red spot on bottom,” describe the observed findings specifically. For example: “Sacral area: skin intact; localized color change compared with surrounding skin; area warmer to touch; patient reports tenderness.” Add the date and time and any other relevant findings.
Respond to new skin changes
When a new darkened area is noticed over a pressure point, inspect it and palpate it if appropriate, and ask the person about pain. Document the location and characteristics, then promptly communicate the change according to local procedure.
Avoid placing the person directly on the affected area when possible, and arrange further assessment as indicated. New skin or tissue changes should prompt review of the person’s .