Open Your Eyes to Skin Assessments

Earlier this year, the National Pressure Injury Advisory Panel invited Medline Clinical Solutions Manager Katie James, BA, RN, CWCN, to present a webinar focused on how to best assess all skin tones. NPIAP Immediate Past President Joyce Black, PhD, RN, FAAN, introduced James, who explored the nuances and challenges of skin assessments and offered NPIAP-driven best practices and helpful resources.

It’s been my passion project over the past three years to study the topic of skin assessments on all skin tones so I can help educate nurses. I fly a lot, and I fly Southwest, so I get to pick my own seats, and I have made it a point to sit next to people who are not of my same skin tone. I have blanched about 200 forearms in the last couple of years just to understand the blanch-ability of different skin tones, and I will tell you, it gets harder and harder after Monk Skin Tone Scale stage 6 to see that blanching. It was very non-scientific, but it was an eye opener to me.

Another firsthand experience with skin assessments happened when my mother fell and broke her femur. The initial skin assessment was cursory at best. Only after I advocated for her did the staff return for a more thorough evaluation. This encounter reinforced my belief that we must do better-not just for our loved ones, but for every patient. This issue isn’t just academic; it’s a matter of equity, quality care and reducing health disparities.

Skin tone is not a side note—it’s central to how we deliver equitable care.

Why skin assessments matter

The population is getting more diverse. Yet, people with dark skin tones are often diagnosed with pressure injuries at later stages. This is well documented and deeply concerning. Textbooks and educational materials have historically favored light-skinned patients, instructing nurses to look for redness—a sign that may not be visible in non-white skin.

There are significant gaps in nursing and medical education regarding skin tone diversity. Many clinicians lack confidence in assessing dark skin, and unconscious bias or outdated language persists in training. It’s not about race—it’s about skin tone. For example, a patient who identifies as Black may have very light skin, or vice versa. Assessments must be tailored to the individual’s skin tone, not assumptions about race. And of course we all are acutely aware of the financial penalties that can exist when missing those pressure injuries and not seeing what we’re supposed to see, especially for non-white skin patients.

Choosing a skin tone scale

Now, having talked about where to assess skin tone, what do you do with that? Well, there are a lot of scales out there, but we honed in on the Monk scale early on in our research at Medline. It’s very clean, very inclusive and doesn’t get out of control with too many options. I think we could make it so complicated that nobody’s going to do it. Our goal is to make it easier to assess skin, not more complex. We can be good with looking at 10 options.

Some people are still prone to the Fitzpatrick scale, but that was really designed for skin cancer risk in light skin tones. When you get to the 5 or 6 on the Fitzpatrick, there’s not a lot of differentiation, so you have a bunch of people in 5 and a bunch of people in 6. That’s where Monk really breaks it out to a more even distribution of the various skin tones. Until technology catches up with this issue, if a patient has a Monk 7 or higher, start them on pressure injury prevention protocols within your facility. I don’t think there’s anything wrong with that.

The power of four

I’m a big believer in the four eyes, four hands approach to skin assessments. It’s not yet universal, but it’s gaining traction in a lot of hospitals. They use it as a way to cut down on present-on-admissions as well as hospital-acquired pressure injuries. While it might not be officially best practice yet, I think it’s a good practice to start. I think it’s a matter of just taking the time during either huddles or educational systems and making it an initiative within your facility to do that. Having a second set of eyes can catch what one person might miss.

Assessing skin through thick creams

One of the questions we tackled was about zinc oxide— specifically, how difficult it can be to assess skin when it’s covered in a thick barrier cream. I’ve seen this firsthand. Zinc is a great barrier, but it’s not always easy to remove, especially from fragile skin. That’s why I recommend using emulsifying cleansers. These products allow the zinc to break down gently, so we can wipe it away without scrubbing or causing harm. It’s a small shift, but it makes a big difference in preserving skin integrity and getting a clear view of what’s underneath.

Bedside nurse ability and approval to assess skin

We heard from one of our webinar attendees that their facility was considering not allowing bedside nurses to stage pressure injuries. It’s within the scope of practice for nurses to be able to stage pressure injuries, but I think a lot of times nurses lack the confidence to feel they can really do it well. It comes down to making sure that the hospitals have those educational pieces in place. Then, when the new Electronic Clinical Quality Measures (eCQM) kick in, charging penalties to hospitals for healthcare-associated stage 2 pressure injuries, those nurses will feel confident in their staging abilities.

Tools and technology that can help

There are some tools and technology out there that can help assess skin. Dr. Black suggests using inexpensive clear, plastic discs, so you can see blanching through them without blocking the area of skin with your finger. Some hospitals are using near-infrared technology, but it’s not affordable for many facilities I visit. I think we’re maybe 10 or 20 years away from having that everywhere. Dr. Black also points out that, even if a facility has an infrared technology device, there are challenges such as moving it from unit to unit, storing it and training staff to use it. So the important thing right now is to educate nurses on how to use the tools they have, which are their senses—except taste!

Moving forward

Comprehensive skin assessments are foundational to patient care. They establish a baseline, help us identify patients at risk and enable early detection of pressure injuries. Early identification is crucial for both clinical and financial outcomes. We must work together to reverse this trend. Assessing dark skin tones requires vigilance, education and empathy. As nurses, we are trained to observe, to notice what others might miss—and that responsibility becomes even more critical when assessing skin tones that don’t fit the textbooks. What I’ve learned through research and personal experience is that we need to challenge outdated norms and equip ourselves with better tools, better language and better habits.

Skin tone is not a side note—it’s central to how we deliver equitable care. Whether it’s choosing the right scale, advocating for thorough assessments or simply taking the time to look again, we have the power to change outcomes. Every patient deserves to be seen, and every nurse deserves the confidence to see clearly.