Perform a full skin inspection, including the pressure points and the skin folds, with the patient repositioned to view the sacrum and heels.
Score pressure-injury risk with the Braden Scale and interpret the total and the subscale drivers.
Distinguish blanchable erythema from non-blanchable erythema — non-blanchable erythema over a bony prominence is a Stage 1 pressure injury (staging in the Wounds / Pressure Injury reference).
Assess for moisture-associated skin damage and describe any lesion by location, size, color, and type.
Reconcile findings with immobility, incontinence, and nutrition, and route any existing wound to the Wounds / Pressure Injury reference.
