Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Skin Assessment

Skin inspection should be based on a comprehensive head-to-toe assessment of those areas known to be vulnerable for each client (see illustrations for at risk areas). This assessment is best conducted when dressing or undressing in order to better visualize vulnerable areas. Any aids (braces, anti-embolic stockings, etc.) should be removed prior to this inspection.

Vulnerable areas typically include:

  • temporal region and occiput of the skull;
  • ears;
  • scapulae;
  • spinous processes;
  • shoulders;
  • elbows;
  • sacrum;
  • coccyx;
  • ischial tuberosities;
  • femoral trochanters;
  • knees;
  • malleoli;
  • metatarsals;
  • heels;
  • toes;
  • areas of the body covered by anti-embolic stockings or restrictive clothing;
  • areas where pressure, friction and shear are exerted during activities of daily living; and
  • parts of the body in contact with devices, such as taping, restraint, tubes, etc.

Additional areas should be inspected as determined by the individual’s condition (NICE, 2001; Weir, 2001).

A comprehensive skin assessment for sites of non-blanching erythema requires both visual and tactile inspection. Early indications of a developing ulcer include:

  • Change in colour (redness/erythema), texture and sensation of the skin surface.
  • In individuals with darkly pigmented skin, observe for persistent erythema, non-blanching hyperemia, blisters and discolouration (purple/blue localized areas), localized heat (replaced by coolness as tissue is damaged), localized edema and localized induration.