A2

Suspected deep-tissue injury

Skilled skin assessment found a maroon, non-blanchable area over the heel with intact but boggy skin — concerning for a suspected deep-tissue injury. Findings indicate a potentially serious pressure injury requiring urgent attention. Provider notified at 10:40 with the finding; order received to offload the heel completely, institute prevention, and refer urgently for wound care. The heel was offloaded with the surface adjusted, prevention instituted, and the caregiver educated; return demonstration accurate. The area was routed to wound care, and reassessment was planned. (Staging in the Wounds / Pressure Injury reference.)

A3

Skin infection — cellulitis

Skilled skin assessment found a spreading area of erythema, warmth, and swelling on the lower leg with tenderness and a low-grade fever — concerning for cellulitis. Findings indicate a skin and soft-tissue infection. Provider notified at 12:00 with the spreading erythema, the warmth, and the fever; order received to evaluate and treat, with instruction to escalate for worsening spread, increasing fever, or systemic symptoms. The borders were noted to track progression, and the patient was educated on the warning signs; teach-back accurate. Reassessment of the area and the systemic response planned, with evaluation coordinated.

A4

Moisture-associated dermatitis

Skilled skin assessment found moisture-associated dermatitis — erythema and superficial denudement in the perineal area — from incontinence, without a pressure component. Findings indicate moisture-associated skin damage at risk of progression. A barrier and structured incontinence-care regimen were instituted; provider notified at 11:30 of the finding and the regimen. Order received to continue the regimen and reassess. The caregiver was taught incontinence care and barrier application; return demonstration accurate. Reassessment of the area planned next visit, distinguishing it from pressure-related breakdown.

A5

Skin tear

Skilled skin assessment found a new skin tear on the forearm in a patient with fragile skin, with the skin flap viable and approximated. Findings indicate a traumatic skin tear. The skin tear was cleansed and the flap approximated and dressed per protocol, and the cause — a transfer — was addressed with padding and technique; provider notified at 12:15 of the tear and the care provided. Skin-tear prevention and protective measures were taught; return demonstration accurate. The tear was routed for ongoing wound monitoring, and reassessment was planned. (Ongoing wound care in the Wounds / Pressure Injury reference.)

A6

Serious skin reaction

Skilled skin assessment found a new widespread rash with areas of blistering and skin tenderness after a recent medication change — concerning for a serious drug reaction. Findings indicate a potentially serious skin reaction. Given the blistering and extent, the provider was contacted immediately at 10:50 and, per severity, emergency evaluation was directed and emergency response activated; the suspected medication was identified for the provider. The patient was monitored and the involved areas protected pending evaluation, and family were informed. The event and communications were documented, with follow-up to coordinate care on return.