Skin integrity — intact skin versus breaks, lesions, or skin tears.
Pressure-injury risk — a Braden Scale assessment (sensory perception, moisture, activity, mobility, nutrition, and friction and shear).
Pressure points — the sacrum, heels, and other bony prominences — for early signs, distinguishing blanchable from non-blanchable erythema.
Moisture-associated skin damage — incontinence-associated dermatitis and intertriginous moisture.
Rashes and lesions — their description, distribution, and concerning features.
Circulation-related skin changes (with Peripheral Vascular) and xerosis or fragility, especially in older adults.
Any existing wound or pressure injury, noted and routed to the Wounds / Pressure Injury reference, and the risk factors of immobility, incontinence, poor nutrition, moisture, and friction and shear.
