5. Abnormal findings

Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:

• Skin breakdown or non-blanchable erythema over a bony prominence (a Stage 1 pressure injury — routed to Wounds / Pressure Injury for staging).
• Elevated pressure-injury risk — a low Braden score with identifiable subscale drivers.
• Moisture-associated dermatitis from incontinence or intertriginous moisture.
• Rashes or lesions with concerning features.
• Xerosis, skin tears, or marked fragility.
• Circulation-related skin changes (with Peripheral Vascular).
• An existing wound or pressure injury (routed to the Wounds / Pressure Injury reference), or uncontrolled risk factors.