Steps for Assessment
1. Review the medical record, including skin care flow sheets
or other skin tracking forms, nurses’ notes, and pressure
ulcer/injury risk assessments.
2. Speak with the treatment nurse and direct care staff on all
shifts to confirm conclusions from the medical record
review and observations of the resident.
3. Examine the resident and determine whether any ulcers,
injuries, scars, or non-removable dressings/devices are
present. Assess key areas for pressure ulcer/injury
development (e.g., sacrum, coccyx, trochanters, ischial
tuberosities, and heels). Also assess bony prominences (e.g.,
elbows and ankles) and skin that is under braces or
subjected to pressure (e.g., ears from oxygen tubing).