Skin assessment in nursing: a step-by-step guide

Skin assessment is the systematic inspection and palpation of the integumentary system to detect abnormalities, monitor for deterioration, and guide clinical decisions. The skin is the body’s largest organ and its condition reflects much more than local pathology — pallor suggests anemia or shock, jaundice signals hepatic dysfunction, mottling indicates circulatory failure, and a Stage 1 pressure injury found on admission can prevent a Stage 4 ulcer three weeks later. For nursing students, developing a consistent, structured skin assessment is one of the highest-yield clinical skills you will learn, because changes in the skin are often the earliest detectable sign that something is wrong systemically.

This guide covers the full skin assessment sequence, primary and secondary lesion terminology, pressure injury staging, the ABCDE rule for suspicious lesions, special population considerations, documentation language, and high-yield NCLEX content. This article focuses on systematic inspection of the whole patient’s skin — color, turgor, temperature, integrity, and lesion morphology. For evaluation of a specific existing wound (measuring wound bed, exudate, tunneling), see the wound assessment guide.

Skin assessment is one component of the full head-to-toe assessment and is performed at admission, at the start of every shift, and whenever a patient reports new skin symptoms.

Overview of the integumentary system

The integument consists of three primary layers, each with distinct clinical relevance.

Epidermis — the outermost layer, composed predominantly of keratinocytes. It is avascular and receives nutrients by diffusion from the dermis below. The epidermis provides the primary physical barrier against pathogens, UV radiation, and fluid loss. The stratum corneum (outermost sublayer) is largely responsible for transepidermal water barrier function.

Dermis — the layer below the epidermis, containing collagen, elastin, blood vessels, lymphatics, nerve endings, hair follicles, and sweat glands. This layer provides structural support and tensile strength. It is the dermis that is lost in partial-thickness wounds and exposed in Stage 3 pressure injuries.

Hypodermis (subcutaneous layer) — the deepest layer, composed of adipose and connective tissue. It functions in thermoregulation (insulation), energy storage, and cushioning of underlying structures. Deep tissue pressure injuries (DTPI) involve damage to subcutaneous tissue before the overlying skin breaks.

The integumentary system serves four key physiological functions nurses must understand:

• Barrier function — prevents pathogen entry and fluid loss
• Thermoregulation — sweat glands, cutaneous blood flow, and adipose insulation regulate core temperature
• Sensation — pain, temperature, pressure, and light touch receptors in the dermis
• Vitamin D synthesis — UV-driven conversion of 7-dehydrocholesterol in the skin

Compromise to any of these functions — through burns, pressure injuries, incisions, or chronic disease — has systemic consequences beyond the skin itself.

Equipment and preparation

Equipment:

• Non-sterile gloves
• Adequate light source (natural or bright overhead; a pen light for mucosal inspection)
• Flexible measuring tape and a small ruler (in centimeters) for any lesions found
• Skin surface thermometer or the dorsum of your ungloved hand for temperature comparison
• Magnifying glass (optional, useful for small lesions)

Environment: Ensure privacy — fully expose the area you are examining, but keep the rest of the patient draped. A well-lit room is essential; dim lighting is the most common reason nurses miss early cyanosis, jaundice, and Stage 1 pressure injuries.

Preparation steps:

1. Perform hand hygiene and don gloves.
2. Introduce yourself, explain what you are doing, and obtain verbal consent.
3. Ask the patient about known skin conditions, new rashes, lesions, itching, or changes in moles.
4. Review the chart for immunosuppression, diabetes, peripheral vascular disease, anticoagulation, or history of pressure injuries — all conditions that heighten skin risk.
5. Ensure adequate warmth; cool room temperatures cause peripheral vasoconstriction and exaggerate pallor, masking true color findings.

Work from head to toe, anterior then posterior. Don’t skip the occiput, sacrum, heels, and other pressure points — these areas are not visible when patients are supine and are consistently missed.

Step-by-step skin assessment

Step 1: Color

Color is assessed across the entire body surface and compared bilaterally. Normal skin color varies enormously across individuals and ethnicities — the clinical significance is always in the change from that patient’s baseline, not an absolute shade.

Key abnormal color findings:

Pallor — generalized loss of color. Common in anemia (reduced hemoglobin), shock (peripheral vasoconstriction shunting blood centrally), hypothermia, and fright. Assess the conjunctivae and mucous membranes — pallor in these sites is more reliable across skin tones than pallor on the dorsum of the hand. Conjunctival pallor is the most reliable sign of anemia on physical exam.

Cyanosis — bluish-purple discoloration from deoxygenated hemoglobin. Distinguish:

• Central cyanosis — lips, tongue, and mucous membranes appear blue. Indicates systemic hypoxemia (SpO2 typically <85%). Causes: pneumonia, pulmonary embolism, right-to-left shunt, severe COPD exacerbation.
• Peripheral cyanosis — distal extremities (fingertips, nail beds, toes) only. Indicates local vasoconstriction or poor perfusion. Causes: cold exposure, Raynaud phenomenon, heart failure, shock. Normal central mucous membranes distinguish peripheral from central.

Jaundice (icterus) — yellow–orange discoloration from bilirubin accumulation. First visible in the sclerae (yellow sclerae = icterus) before becoming apparent in skin. Assess by examining the sclerae in natural light. Causes: hepatic dysfunction (hepatitis, cirrhosis), hemolytic anemia, biliary obstruction, neonatal physiological jaundice. Do not confuse with hypercarotenemia (excessive beta-carotene intake), which turns the skin yellow but spares the sclerae.

Erythema — redness from cutaneous vasodilation. Localized erythema over a joint may indicate infection or inflammation; a malar rash (butterfly distribution) suggests systemic lupus erythematosus; widespread erythema after a new medication may signal a drug reaction.

Mottling — irregular, blotchy, lace-like pattern of reddish-blue discoloration, most visible on the knees and legs. In an acutely ill patient, mottling indicates severely reduced peripheral perfusion and is a marker of circulatory failure. It should trigger immediate escalation.

Bronze/hyperpigmentation — diffuse bronze-brown discoloration can indicate Addison disease (adrenal insufficiency) from excess ACTH stimulating melanocytes.

Step 2: Temperature and moisture

Palpate the skin with the dorsum of your hand, which is more temperature-sensitive than the palm. Compare bilateral areas simultaneously when possible.

Temperature findings:

• Warm, bilateral — normal
• Cool or cold bilaterally — peripheral vasoconstriction (cold environment, shock, hypothyroidism, peripheral vascular disease)
• Localized warmth — inflammation, infection, deep vein thrombosis (unilateral calf warmth)
• Localized coolness distal to a point — vascular occlusion; compare temperature above and below the level of concern

Moisture findings:

• Diaphoresis (profuse sweating) — a high-priority finding. Causes: sympathetic activation (pain, anxiety, MI, hypoglycemia), fever/defervescence, sepsis, hyperthyroidism, opiate withdrawal, menopause. Cold diaphoresis (sweating with cool, clammy skin) strongly suggests sympathetic surge — think hypoglycemia or cardiogenic shock.
• Dry skin (xerosis) — common in elderly patients, patients with hypothyroidism, chronic kidney disease, or dehydration. Severe xerosis produces cracking and fissure formation, creating entry points for infection.
• Oily/greasy skin — may indicate hyperthyroidism or seborrheic conditions.

Step 3: Turgor

Skin turgor reflects tissue hydration and is assessed by gently pinching a fold of skin, lifting it, releasing, and watching how quickly it returns to baseline.

Technique: In adults, use the skin over the forearm or clavicle. In children under 2, use the abdomen. Do NOT use the dorsum of the hand to assess dehydration in elderly patients — see aging caveat below.

Findings:

• Normal (elastic): Skin snaps back immediately upon release (<2 seconds).
• Tenting (poor turgor): Skin remains elevated for >2 seconds before returning to baseline. Indicates significant dehydration or fluid volume deficit.

Aging caveat — critical for practice: Skin loses elasticity with age due to decreased collagen and elastin. In patients over approximately 65, skin on the dorsum of the hand will tent even when the patient is well-hydrated — this is a normal age-related change, not a sign of dehydration. Always use the forearm or clavicular skin to assess turgor in elderly patients. Many students and some nurses make the error of documenting poor turgor in an elderly patient based on hand assessment alone, which leads to unnecessary IV fluid administration.

Step 4: Texture and thickness

Run the flat of your hand across larger skin surfaces and use fingertip palpation to assess discrete lesions.

Normal texture: Smooth, soft, consistent across body regions (with expected variation — palmar skin is thicker than eyelid skin).

Abnormal texture findings:

• Lichenification — thickened, leathery skin with exaggerated skin markings from chronic rubbing or scratching. Associated with chronic eczema, contact dermatitis, and pruritic conditions.
• Scaling — dry, flaking keratin on the skin surface. Causes include psoriasis (silvery-white scales), seborrheic dermatitis (greasy yellow scales), ichthyosis, and fungal infections.
• Roughness — generalized roughness may indicate hypothyroidism (myxedema), keratosis pilaris, or chronic sun damage.
• Induration — firm, raised, non-pitting hardening; found in cellulitis, scleroderma, and fibrotic wound healing.
• Atrophy — thinning and translucency of the skin from prolonged topical corticosteroid use, aging, or autoimmune disease.

Step 5: Integrity

Inspect for any disruption to the skin surface: wounds, pressure injuries, tears, bruising, rashes, or lesions.

Intact versus impaired:

• Document each area of impaired integrity with precise location, size, and characteristics (see Documentation section below).
• Check IV insertion sites for phlebitis (erythema, warmth, induration along the vein tract, pain, cord-like feel).
• Inspect all pressure points systematically: occiput, ears, scapulae, elbows, sacrum/coccyx, ischial tuberosities, greater trochanters, lateral malleoli, and heels.

Ecchymosis (bruising): Note size, location, color, and shape. Recent bruises are red-purple; older bruises progress through blue-green to yellow as hemoglobin is metabolized. Multiple unexplained bruises or bruises in unusual locations warrant safeguarding consideration (elder abuse, child abuse, intimate partner violence) and must be documented objectively and reported per facility protocol.

Primary and secondary skin lesions

Accurate lesion terminology is foundational to nursing documentation and interprofessional communication. Primary lesions develop directly from a pathological process; secondary lesions evolve from changes to primary lesions over time or from manipulation.

Primary lesions

Secondary lesions

Pressure injury staging

Pressure injuries develop when sustained mechanical load over a bony prominence impairs local blood flow, causing ischemic tissue death. The National Pressure Injury Advisory Panel (NPIAP) staging system classifies injuries by depth of tissue involvement. Staging requires identifying the deepest type of tissue visible or palpable — not the size.

Stage 1 vs DTPI — a high-yield NCLEX discriminator: Both present with intact skin over a bony prominence, and both are non-blanchable. The distinction: Stage 1 shows red erythema that is superficial and consistent with local ischemic hyperemia of the dermis. DTPI shows purple, maroon, or dark discoloration — or a blood-filled blister — reflecting hemorrhage and destruction of deeper tissue (subcutaneous fat, muscle) before the skin surface has broken. DTPI often evolves rapidly to expose deep tissue loss over days. If you see purple-maroon discoloration over the heel with intact skin, document DTPI — not Stage 1.

Braden Scale for predicting pressure injury risk:

The Braden Scale quantifies a patient’s risk using six subscales. Total scores range from 6 (highest risk) to 23 (lowest risk). A score ≤18 indicates risk; ≤9 indicates very high risk.

Patients at risk (Braden ≤18) require a pressure injury prevention protocol: 2-hour repositioning, pressure-redistributing mattress/cushion, heel offloading, moisture barrier cream for incontinence, and nutrition optimization. Skin assessment over pressure points is performed at every repositioning.

The Braden Scale is not a substitute for clinical judgment — a patient with a Braden score of 19 who is post-cardiac surgery and on vasopressors has significant unlisted risk factors. Supplement the score with your own integumentary and vascular findings.

ABCDE rule for skin lesions

The ABCDE mnemonic is used during nursing skin assessment to identify suspicious pigmented lesions that may represent melanoma or other malignant skin changes. It should be applied to any mole, pigmented lesion, or growth that the patient has noticed changing.

A — Asymmetry: One half of the lesion does not mirror the other. Benign nevi are typically round or oval and symmetric. Asymmetric lesions warrant referral.

B — Border: Irregular, ragged, notched, or blurred borders are concerning. Benign moles have smooth, well-defined edges.

C — Color: Variation in color within a single lesion — multiple shades of brown, black, tan, red, white, or blue — increases suspicion. Uniform tan or brown coloring is more consistent with benign nevi.

D — Diameter: Lesions >6 mm (approximately the diameter of a pencil eraser) are more concerning, though melanomas can be smaller, particularly at early stages. Document exact size in millimeters using a ruler.

E — Evolving: Any change in size, shape, color, or symptoms (itching, bleeding, crusting) over weeks to months. Evolving is now considered the most clinically sensitive criterion — a lesion that has not changed in decades carries far less concern than one the patient reports is “growing.”

When to escalate: One or more ABCDE criteria present in a pigmented lesion warrants referral to dermatology or primary care for evaluation. Do not reassure the patient that it is “probably fine” — document the findings objectively and notify the provider. High-risk patients include those with fair skin, extensive sun exposure history, personal or family history of melanoma, or immunosuppression.

Skin assessment in special populations

Elderly patients

Aging skin undergoes predictable changes that alter normal findings:

• Decreased turgor — loss of collagen and elastin produces skin that tents on the hand even when hydrated. Use the forearm or clavicular skin; never rely on dorsal hand turgor in patients over 65.
• Thinning and fragility — the epidermis thins with age and the dermis loses supporting connective tissue, making the skin prone to tears, bruising, and shearing injuries. A standard blood pressure cuff can cause a skin tear in a frail elderly patient.
• Dryness — sebaceous and sweat gland output declines, producing xerosis. Severe dryness causes pruritus and fissuring.
• Lentigo senilis (age spots) — flat, brown hyperpigmented macules on sun-exposed skin; benign, but must be differentiated from lentigo maligna (a form of melanoma in situ). Apply ABCDE criteria to any age spot the patient has noticed changing.
• Actinic keratoses — rough, scaly patches on sun-damaged skin; premalignant lesions that require dermatology follow-up.
• Slower wound healing — reduced inflammatory response and cell turnover mean that wounds heal more slowly in elderly patients and are more vulnerable to secondary infection.

Patients with darker skin tones

This is one of the most clinically important — and most under-taught — aspects of skin assessment. Standard descriptions of skin findings (erythema, pallor, cyanosis) assume light-colored skin. In patients with darker skin tones, these changes may be invisible or subtly different in appearance.

Erythema detection in dark skin tones:

• Color change may be less obvious. Look for a change relative to the patient’s own surrounding skin — a subtle darkening, a purplish or brown-red hue, or a difference in luminance compared to the contralateral side.
• Palpation is essential. Warmth on palpation is a reliable indicator of inflammation regardless of skin color. If the area over a bony prominence feels warmer than surrounding tissue, treat it as early pressure injury even if you cannot see erythema.
• Ask the patient. Pain or burning sensation in a pressure-bearing area without visible skin change is a valid clinical finding — document it and act on it.
• Subepidermal moisture. Early pressure-induced damage increases subepidermal moisture before visible skin changes occur. Palpate for changes in moisture, firmness, or boggy texture.
• Pallor and cyanosis are most reliably assessed in mucosal surfaces: conjunctivae (pallor), oral mucosa and tongue (cyanosis), nail beds, and palmar surfaces.

Failing to assess dark-skinned patients thoroughly is a documented health equity gap. Patients with darker skin develop pressure injuries at the same rate as lighter-skinned patients but are more likely to be identified at a later, more severe stage.

Pediatric patients

• Mongolian spots — blue-gray macules over the sacrum and buttocks in infants, especially in Asian, Black, and Hispanic newborns. They are benign, fade over years, and must be documented clearly to distinguish them from bruising. Failure to document can result in unnecessary safeguarding concerns.
• Birthmarks — port-wine stains (capillary malformations), hemangiomas (soft, raised, bright red), and café-au-lait spots are normal variants. Multiple café-au-lait spots (≥6 in prepubertal children) may indicate neurofibromatosis.
• Milia — tiny white cysts on the nose and face of newborns; resolve spontaneously.
• Rashes — differentiate viral exanthems (symmetric, often starts on trunk), contact dermatitis (localized to exposed area), and petechiae (non-blanching, may indicate thrombocytopenia or meningococcemia — escalate immediately).

Patients with edema

Edema changes skin assessment findings significantly. Edematous skin:

• Appears shiny, taut, and translucent
• May show pitting (press firmly for 5 seconds with your thumb and release — graded 1+ to 4+)
• Loses the ability to hold lesion landmarks accurately
• Is highly vulnerable to breakdown — pressure injuries can develop within hours under taut, poorly-perfused edematous tissue
• May weep (anasarca) — document any serous drainage and protect the area from skin breakdown

Documentation language

Accurate, standardized documentation protects the patient (ensures findings transfer between providers), protects the nurse (establishes what was assessed and when), and drives treatment decisions. Use objective, anatomically precise language. Avoid vague terms such as “skin intact” without further detail, and avoid interpretive language (“looks infected”) without objective findings.

Required elements for any lesion or abnormality:

1. Location — anatomical site plus relationship to landmarks (e.g., “2 cm lateral to the right ischial tuberosity”; “over the left lateral malleolus”)
2. Size — measure in centimeters: length × width; add depth for wounds
3. Shape/border — round, oval, irregular, well-demarcated vs diffuse
4. Color — use objective descriptors (erythematous, blanching/non-blanching, purple-maroon, yellow, black)
5. Surface — intact, crusted, scaly, weeping, granulating
6. Drainage — if present: amount (scant, moderate, copious), color, consistency, odor

Example narrative documentation note:

“Integumentary assessment: Skin warm, dry, intact across anterior chest and bilateral upper extremities. No rashes, lesions, or bruising noted. Pressure point assessment: 1.5 × 1.0 cm area of non-blanchable erythema noted over the sacrum; skin intact; area warmer than surrounding tissue on palpation; no drainage. NPIAP Stage 1 pressure injury. Wound care notified. Bilateral heels suspended off mattress. Braden scale score 14 — at risk per protocol. Repositioning q2h initiated.”

NCLEX tips

High-yield concepts for NCLEX skin assessment questions:

• Blanching test: Press firmly on erythematous skin for 3 seconds and release. Blanchable erythema (skin turns white on pressure) = reactive hyperemia, not a pressure injury. Non-blanchable erythema = Stage 1 pressure injury minimum.
• Stage 1 vs DTPI: Stage 1 = red, non-blanchable, intact skin. DTPI = purple/maroon, non-blanchable, intact skin OR blood-filled blister. The distinction drives different documentation and care intensity.
• Braden scale cut-offs: Score ≤18 = at risk. Score ≤12 = high risk. Score ≤9 = very high risk. Lower score = more risk.
• Braden scale: 6 subscales — sensory perception, moisture, activity, mobility, nutrition, friction/shear. Friction/shear is scored 1–3 (max 3, not 4).
• Turgor in elderly: Use forearm or clavicle, NOT the dorsum of the hand. Decreased turgor on the hand is normal in older adults.
• Jaundice vs pallor: Jaundice — sclerae turn yellow first. Pallor — check the conjunctivae (best site across all skin tones).
• Central vs peripheral cyanosis: Central = lips, tongue, oral mucosa. Peripheral = fingertips and nail beds only. Central cyanosis indicates systemic hypoxemia; peripheral can be benign in cold environments.
• Diaphoresis with cool, clammy skin = sympathetic activation. Think hypoglycemia, cardiogenic shock, MI, or opiate withdrawal.
• ABCDE rule: Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolving. Any positive criterion requires escalation.
• Mongolian spots vs bruising: Mongolian spots are non-tender, flat, blue-gray, present at birth, fade with age. Document on admission to avoid safeguarding misinterpretation.
• Pitting edema grading: 1+ = 2 mm rebound in <15 sec; 2+ = 3–4 mm; 3+ = 5–6 mm; 4+ = >6 mm with >30 sec rebound.
• Erythema in dark skin: Rely on palpation (warmth), patient report (pain/burning), and subepidermal moisture — not visual redness alone.
• Skin tears in elderly: Caused by friction and shear; fragile skin from corticosteroid use or aging. Prevention = long sleeves, silicone dressings on high-risk areas, careful pad/tape removal.
• Petechiae — pinpoint, non-blanchable red spots <3 mm. Non-blanchable confirms they are hemorrhagic, not vascular. Possible causes: thrombocytopenia, meningococcemia, endocarditis. Escalate immediately.
• Integumentary assessment includes IV sites: Always inspect the IV insertion point for phlebitis (redness, warmth, induration, cord-like vein), infiltration (swelling, pallor, coolness), and extravasation (vesicant infiltration — particularly urgent).

NCLEX scenarios

Scenario 1

A nurse is performing a skin assessment on a patient who has been in the ICU for 5 days. Over the patient’s right heel, the nurse notes a 2 × 2 cm area of purple-maroon discoloration with intact skin, no blanching on pressure, and a firm, boggy texture compared to the surrounding tissue. How should the nurse document this finding?

A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep Tissue Pressure Injury (DTPI)
D. Unstageable pressure injury

Correct answer: C

Rationale: Purple-maroon discoloration with intact skin, non-blanchable, and a boggy texture on palpation is the classic presentation of DTPI — deep tissue damage occurring before the surface breaks. Stage 1 presents with red (not purple/maroon) non-blanchable erythema. Stage 2 has partial-thickness skin loss. Unstageable is covered by slough or eschar. DTPI is frequently tested on NCLEX because students confuse it with Stage 1.

Scenario 2

A nurse calculates a Braden scale score of 13 for a newly admitted patient. Which intervention is the nurse’s highest priority based on this score?

A. Apply moisturizing lotion to dry skin areas
B. Initiate 2-hour repositioning and pressure-redistributing surface
C. Document the score and reassess in 24 hours
D. Apply a heel wedge to prevent foot drop

Correct answer: B

Rationale: A Braden score of 13 falls in the high-risk category (≤14 per many institutional protocols; ≤12 by NPIAP thresholds). The highest-priority intervention is pressure injury prevention: initiating a repositioning schedule and placing the patient on a pressure-redistributing surface. Moisturizing lotion and documentation alone do not address the pressure risk. Heel wedges prevent foot drop, not pressure injuries — heel offloading devices are needed instead.

Scenario 3

A nurse is assessing an 82-year-old female patient for dehydration following three days of decreased oral intake. The nurse pinches the skin on the dorsum of the hand and notes it remains tented for 4 seconds. What is the most accurate interpretation of this finding?

A. The patient is severely dehydrated and requires immediate IV fluids
B. The finding is a normal age-related change and should not be used to assess hydration
C. The finding confirms dehydration and correlates with serum osmolarity
D. The patient requires a Braden scale assessment

Correct answer: B

Rationale: In elderly patients, skin on the dorsum of the hand loses elasticity as a normal aging change. Tenting on the hand in a patient over 65 does not indicate dehydration and should not be used for turgor assessment. The forearm or clavicular skin is the correct assessment site in elderly patients. Hydration status in elderly patients should be corroborated with mucous membrane moisture, urine output, weight, and serum electrolytes.

Scenario 4

A nurse is performing a skin assessment on a patient with darker skin tone. The patient reports a burning sensation under their left ischial tuberosity. On inspection, the nurse cannot clearly detect erythema but notes the area feels warmer than the surrounding tissue. What is the nurse’s best next action?

A. Document “skin intact, no abnormalities noted” and reassess in 4 hours
B. Treat the finding as a pressure injury risk, offload the area, and document warmth and patient complaint
C. Apply a heat pack to improve circulation
D. Administer a topical corticosteroid for suspected eczema

Correct answer: B

Rationale: In patients with darker skin tones, erythema may not be visually apparent, but warmth on palpation and the patient’s self-report of burning sensation are valid clinical indicators of pressure-related tissue damage. The nurse should treat this as a suspected Stage 1 pressure injury (or early DTPI risk), offload the pressure immediately, and document the objective finding (warmth on palpation) plus the patient’s complaint. Documenting “no abnormalities” would be inaccurate and a safety failure.

Scenario 5

During a skin assessment, a nurse identifies a 7 mm pigmented lesion on a patient’s back with irregular, notched borders and color variation ranging from tan to dark brown to black. The patient states it has been “getting bigger” over the past two months. What is the nurse’s priority action?

A. Reassure the patient that most moles are benign and schedule a dermatology appointment at the next annual visit
B. Apply ABCDE criteria, document objectively, and notify the provider immediately
C. Take a photograph and place it in the chart as documentation
D. Cover the lesion with a dressing to protect it from friction

Correct answer: B

Rationale: This lesion meets multiple ABCDE criteria — irregular Border, Color variation, Diameter >6 mm, and Evolving (patient reports growth). The nurse’s role is to document objective findings using the ABCDE framework and notify the provider for evaluation. Reassurance and deferral are inappropriate given multiple high-risk features. A photograph alone does not constitute action. Covering the lesion delays evaluation.

Clinical sources

• National Pressure Injury Advisory Panel (NPIAP). NPIAP Pressure Injury Stages. npiap.com, 2016 (updated terminology 2019).
• Bickley LS, Szilagyi PG, Hoffman RM. Bates’ Guide to Physical Examination and History Taking, 13th ed. Wolters Kluwer, 2021.
• Potter PA, Perry AG. Fundamentals of Nursing, 11th ed. Elsevier, 2023.
• Dains JE, Baumann LC, Scheibel P. Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th ed. Elsevier, 2019.
• Shenefelt PD. “Skin Disorders in Older Adults.” StatPearls [Internet]. NCBI, updated 2024.
• Padula WV, Delarmente BA. “The national cost of hospital-acquired pressure injuries in the United States.” Int Wound J. 2019;16(3):634–640.
• Browne NT et al. “Assessing pressure injury risk in patients with darker skin tones.” Wounds. 2022.
• National Council of State Boards of Nursing (NCSBN). NCLEX-RN Test Plan 2023.