Champion Inclusive Care With Assessments for All Skin Types

The population of the United States is aging, and it’s also growing more diverse. By the year 2050, the non-Caucasian population of the United States will grow by 45%.¹ It means your patient and resident population is changing, and it’s more important than ever to understand skin care best practices, especially for patients with diverse skin tones.

Lack of experience with assessing diverse skin tones can lead to health inequities in practice and poor health outcomes. For example, people with dark skin are often diagnosed with pressure injuries at later stages than people with light skin.²

Help empower your team to follow best practices for assessing skin integrity for all skin tones and improve outcomes.

When to conduct skin checks or assessments

Skin and tissue assessments should be conducted:

• As soon as possible after admission to your unit or transfer from another unit or facility
• Ongoing, each time you encounter the patient or resident
• As part of every risk assessment
• Periodically as indicated by the individual’s degree of pressure injury risk
• Prior to discharge from your care

But there are challenges that may stand in the way of success. Before your team can achieve successful skin assessments, be aware of these 4 main challenges:

1. Nurse education often overlooks the differences between light and dark skin. Textbook materials and images have historically favored light skin, such as instructing nurses to look for “redness.”³ NPIAP has said, “Education provided to nurses and other clinicians related to assessment of people with diverse skin colors is sadly lacking.”⁴

2. Diverse skin tone coloration and difficulty seeing skin blanching makes it more difficult to visually assess skin that’s darkly pigmented in order to identify early signs of breakdown or pressure injuries.

3. Nursing staff often lacks confidence when assessing diverse skin tones because guidance is relatively new and very little supporting education exists to help train staff.

4. Viewing dark skin as “different” skin—instead of one skin attribute among many—can come from inadequate education and training. In fact, as NPIAP states, “The race of a patient should no longer be used as a demographic term or a risk factor for PIs.” Language and attitudes have been stuck in a certain pattern, so changing that will require an adjustment through all levels of healthcare.

Stress the “why” of comprehensive skin assessments

Despite the challenges, skin assessments continue to be an integral part of daily routines. To help overcome the challenges and improve patient outcomes, educate your team on the why behind what they do each day:

1. Identifying at-risk skin helps determine proper interventions.
2. Detecting pressure injuries in early stages helps treat wounds and prevent them from worsening.
3. In-depth skin assessments that take skin tone into consideration reduce health disparities.
4. Proper documentation of skin conditions helps avoid facility financial penalties.

Assessing all skin

An in-depth skin assessment protocol covers 4 essential concepts: prep, pigment, palpate and pain.

Prep
The preparation for a skin assessment includes several components such as getting a thorough medical history, cleansing the skin and moistening skin, especially dark skin. The higher lipid content in dark skin can mean it’s more susceptible to transepidermal water loss and xerosis, resulting in dry, scaly and ashen skin. To moisten, some experts recommend using dabs of tap water,5 but you may prefer or require sterile water, saline or a wipe.

Pigment
Visual cues are an important part of preventing pressure injuries. Discoloration might look purple, blue or violet, depending on skin tone. To see truer colors of the skin and more clearly identify discoloration, use either natural light, a pen light, your phone flashlight, or a halogen flashlight or lamp. The light should be white or as close to daylight as possible. This assistive lighting is crucial when assessing patients with dark skin tones. In addition, compare skin areas of concern with adjacent skin or a counterpart on the body that is unaffected.⁵ One thing to note is that digital photography is often not optimized to register dark skin as well as light skin.

2 new skin assessment resources

1. Medline conducted a comprehensive literature review to help develop an e-book and one-page poster that provides memorable education to empower staff to assess skin integrity for all skin tones. The Anatomy of a Skin Assessment™ is available for download.

2. After reviewing the e-book and poster, the National Pressure Injury Advisory Panel was inspired to partner with Medline to create a guide that helps staff properly inspect darkly pigmented skin.

Palpate
The sense of touch is an important element to achieve an in-depth skin assessment. Be sure to use the pads of four fingers of one hand to palpate for induration, bogginess and edema, and not just a single finger poke. Use the back of your hand to palpate for temperature. Localized areas of temperature differences provide a clue to damage.⁶

Pain
Be aware of non-verbal cues that may signal skin damage. While palpating the skin, ask the patient whether they’re experiencing any discomfort or sensation changes, such as tingling or numbness. In dark skin, studies show that bogginess and pain were often common signs of a stage 1 pressure injury.⁷